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The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10943.06,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3522.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"minimum":2578.9,"maximum":8201.99,"setting":"inpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8201.99,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2578.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"minimum":13748.55,"maximum":22512.02,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20186.4,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22512.02,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":18038.08,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20591.54,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13748.55,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"minimum":70652.4,"maximum":70652.4,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":70652.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"minimum":5622.22,"maximum":5622.22,"setting":"inpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5622.22,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"minimum":8656.42,"maximum":8656.42,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8656.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"minimum":9156.34,"maximum":9156.34,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9156.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"minimum":8054.74,"maximum":8054.74,"setting":"inpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8054.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"minimum":8383.19,"maximum":9853.2,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9853.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":97.1,"estimated_amount":8383.19,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"minimum":12287.98,"maximum":18699.28,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15139.8,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18699.28,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12287.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"minimum":9491.77,"maximum":9491.77,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9491.77,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"minimum":13915.64,"maximum":13915.64,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13915.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peritoneal Adhesiolysis Without Cc/Mcc","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"minimum":5108.21,"maximum":5108.21,"setting":"inpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":77.0,"estimated_amount":5108.21,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Digestive Malignancy With Cc","code_information":[{"code":"375","type":"MS-DRG"}],"standard_charges":[{"minimum":2668.49,"maximum":2668.49,"setting":"inpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2668.49,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"minimum":12104.6,"maximum":12104.6,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12104.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"minimum":9923.98,"maximum":17298.82,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9923.98,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":77.0,"estimated_amount":14974.63,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17298.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"minimum":3740.96,"maximum":19164.29,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15390.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4704.25,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19164.29,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":10829.64,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3740.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"minimum":5868.4,"maximum":7225.0,"setting":"inpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5868.4,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7225.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"minimum":5760.72,"maximum":5760.72,"setting":"inpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5760.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"minimum":7214.25,"maximum":7214.25,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7214.25,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"minimum":9228.09,"maximum":9228.09,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9228.09,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Osteomyelitis Without Cc/Mcc","code_information":[{"code":"541","type":"MS-DRG"}],"standard_charges":[{"minimum":8599.75,"maximum":8599.75,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8599.75,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","code_information":[{"code":"556","type":"MS-DRG"}],"standard_charges":[{"minimum":39781.9,"maximum":39781.9,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":39781.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"minimum":3456.6,"maximum":3456.6,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3456.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"minimum":4978.31,"maximum":8621.79,"setting":"inpatient","payers_information":[{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6097.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4978.31,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8621.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"minimum":4519.37,"maximum":4519.37,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4519.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"minimum":14543.51,"maximum":30868.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":97.1,"estimated_amount":14543.51,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30868.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"minimum":7131.5,"maximum":14529.09,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14529.09,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":77.0,"estimated_amount":7131.5,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14085.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"minimum":4799.62,"maximum":8503.2,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4799.62,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8503.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"minimum":30649.26,"maximum":30649.26,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30649.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"minimum":7235.28,"maximum":35326.2,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.4,"estimated_amount":18364.08,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35326.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19522.0,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7235.28,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":33082.64,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29337.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"minimum":29541.44,"maximum":29541.44,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29541.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"minimum":3456.6,"maximum":5006.05,"setting":"inpatient","payers_information":[{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5006.05,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3456.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","code_information":[{"code":"854","type":"MS-DRG"}],"standard_charges":[{"minimum":13430.1,"maximum":13430.1,"setting":"inpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13430.1,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","code_information":[{"code":"857","type":"MS-DRG"}],"standard_charges":[{"minimum":13969.7,"maximum":13969.7,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13969.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","code_information":[{"code":"871","type":"MS-DRG"}],"standard_charges":[{"minimum":5046.6,"maximum":18443.52,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5046.6,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15558.22,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11995.77,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11128.56,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18443.52,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13549.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","code_information":[{"code":"872","type":"MS-DRG"}],"standard_charges":[{"minimum":4602.67,"maximum":19668.27,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7949.55,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9283.74,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":19668.27,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4602.67,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11571.16,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5446.82,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11788.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"minimum":71633.0,"maximum":71633.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":71633.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","code_information":[{"code":"897","type":"MS-DRG"}],"standard_charges":[{"minimum":4661.6,"maximum":4661.6,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4661.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"minimum":85792.2,"maximum":85792.2,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":85792.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Signs And Symptoms Without Mcc","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"minimum":31456.44,"maximum":31456.44,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":31456.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Goserelin acetate implant","code_information":[{"code":"0810","type":"APC"}],"standard_charges":[{"minimum":3154.08,"maximum":3154.08,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3154.08,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Euflexxa inj per dose","code_information":[{"code":"0875","type":"APC"}],"standard_charges":[{"minimum":132.96,"maximum":132.96,"setting":"outpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":132.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Monovisc inj per dose","code_information":[{"code":"1747","type":"APC"}],"standard_charges":[{"minimum":949.41,"maximum":949.41,"setting":"outpatient","payers_information":[{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":949.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Clinic Visits and Related Services","code_information":[{"code":"5012","type":"APC"}],"standard_charges":[{"minimum":22.35,"maximum":195.07,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":108.76,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":35.34,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":58.03,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.77,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":104.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":89.98,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":160.24,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":37.23,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":70.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.26,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":151.92,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35.45,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":114.0,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":27.79,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":88.78,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":51.15,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":195.07,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":50.13,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22.35,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":49.14,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":34.63,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":189.76,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":56.24,"methodology":"percent of total billed charges"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":69.92,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":107.84,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":114.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":33.0,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"minimum":58.15,"maximum":410.88,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":175.26,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":295.57,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":150.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":181.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":102.3,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":160.23,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":117.87,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":58.15,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":109.94,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":410.88,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":179.77,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":86.26,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"minimum":158.1,"maximum":1036.1,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":699.13,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":261.48,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":361.6,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":167.58,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":768.67,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":822.5,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":164.01,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":195.72,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":486.41,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":199.45,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":165.49,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":197.21,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":158.1,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":715.28,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":236.54,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":189.58,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":257.7,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":795.59,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1036.1,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":312.14,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":166.7,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":691.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":162.54,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":170.12,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"minimum":199.45,"maximum":1761.94,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1626.78,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":547.72,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":732.88,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":309.91,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1405.76,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1382.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":287.79,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":500.44,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1075.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":199.45,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":249.06,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":324.88,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":257.06,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":1317.44,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":509.58,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":265.05,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":482.46,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1761.94,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":638.71,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":662.46,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":256.57,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":947.16,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1324.55,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":246.37,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":499.44,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"minimum":552.10,"maximum":5409.98,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3660.18,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1538.74,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2401.66,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":827.73,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3749.77,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":866.82,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1511.50,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2460.73,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1838.42,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":833.36,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1091.66,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":641.56,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2191.91,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":3239.24,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1640.7,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":552.10,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1555.42,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4856.54,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5409.98,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1655.15,"methodology":"percent of total billed charges"},{"payer_name":"Medigold","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1527.1,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":655.31,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1711.58,"methodology":"percent of total billed charges"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":3722.73,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3655.35,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":841.04,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1706.16,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"minimum":541.95,"maximum":20728.61,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5326.26,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2146.07,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2602.22,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1125.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4505.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20728.61,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":589.77,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2351.30,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4170.58,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4669.44,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":716.54,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1539.54,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":576.78,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":3803.02,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2978.47,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":944.02,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2622.87,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4392.22,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2312.21,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":541.95,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5283.73,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":796.13,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2383.37,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"minimum":1905.18,"maximum":16013.65,"setting":"outpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1905.18,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4618.98,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13073.03,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16013.65,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":5637.38,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"minimum":123.51,"maximum":1110.3,"setting":"outpatient","payers_information":[{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":515.53,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1110.3,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":355.94,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":462.42,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":123.51,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":449.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"minimum":413.32,"maximum":2439.96,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":634.86,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":413.32,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":545.54,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1665.7,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":666.24,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":520.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":2439.96,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":901.75,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"minimum":579.61,"maximum":4029.77,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4029.77,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":579.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"minimum":813.14,"maximum":2963.11,"setting":"outpatient","payers_information":[{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":813.14,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":1343.3,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":901.33,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2963.11,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"minimum":1651.41,"maximum":17102.61,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14886.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16289.77,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1651.41,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17102.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"minimum":2864.68,"maximum":23805.11,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23805.11,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2864.68,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":21237.19,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3033.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"minimum":4993.68,"maximum":28382.3,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28382.3,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5411.56,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4993.68,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Strapping and Cast Application","code_information":[{"code":"5102","type":"APC"}],"standard_charges":[{"minimum":331.34,"maximum":331.34,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":331.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"minimum":1094.2,"maximum":11264.46,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3034.91,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9293.73,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1094.2,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2055.75,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1283.61,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11264.46,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"minimum":3068.39,"maximum":34666.42,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34666.42,"methodology":"other"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":5860.33,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22937.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3339.14,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4023.51,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3068.39,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22381.79,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":9947.61,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"minimum":13493.22,"maximum":49439.05,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32420.12,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":13493.22,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":49439.05,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":39031.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"minimum":13022.36,"maximum":52249.02,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14752.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":22011.99,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14278.8,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13022.36,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":52249.02,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":13444.74,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13205.67,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":50432.66,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":24311.36,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Airway Endoscopy","code_information":[{"code":"5151","type":"APC"}],"standard_charges":[{"minimum":173.96,"maximum":714.55,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":714.55,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":204.91,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":633.74,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":646.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":196.27,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":204.91,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":192.73,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":175.77,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":204.91,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":205.11,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":196.86,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":176.44,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":544.66,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":173.96,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":627.95,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.96,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":176.26,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Airway Endoscopy","code_information":[{"code":"5154","type":"APC"}],"standard_charges":[{"minimum":36584.54,"maximum":36584.54,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":36584.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 ENT Procedures","code_information":[{"code":"5162","type":"APC"}],"standard_charges":[{"minimum":144.19,"maximum":1780.73,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":762.24,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":144.19,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1780.73,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 ENT Procedures","code_information":[{"code":"5163","type":"APC"}],"standard_charges":[{"minimum":1534.24,"maximum":11108.88,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7988.68,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2569.71,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11108.88,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1534.24,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1790.31,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8774.58,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2432.49,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 ENT Procedures","code_information":[{"code":"5164","type":"APC"}],"standard_charges":[{"minimum":2342.35,"maximum":17779.71,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":7539.06,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3425.41,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2342.35,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2403.41,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17779.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 ENT Procedures","code_information":[{"code":"5165","type":"APC"}],"standard_charges":[{"minimum":2403.41,"maximum":20211.72,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13306.67,"methodology":"other"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2495.59,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14394.81,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12596.52,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2429.91,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2588.12,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14876.63,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2403.41,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20211.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Vascular Procedures","code_information":[{"code":"5182","type":"APC"}],"standard_charges":[{"minimum":1476.84,"maximum":4365.7,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4365.7,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3661.08,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1476.84,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"minimum":4391.83,"maximum":25839.29,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":8065.4,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6772.76,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":8558.34,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20837.03,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21354.15,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25839.29,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4391.83,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"minimum":161.48,"maximum":10326.56,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":6317.46,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10326.56,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1319.62,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":161.48,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":584.52,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1024.49,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"minimum":1214.53,"maximum":8874.90,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3982.78,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3044.49,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1357.42,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8874.90,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2496.41,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1322.72,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2547.85,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2952.71,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8518.32,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7937.86,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2461.05,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1214.53,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5362.24,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1309.79,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2101.27,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"minimum":3246.31,"maximum":14625.63,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3246.31,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14625.63,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"minimum":1491.46,"maximum":9399.31,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7639.44,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3052.13,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1548.68,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7370.26,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6926.19,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1565.49,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2231.80,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1564.58,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":6574.81,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4649.22,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3307.84,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8311.42,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7835.08,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1491.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9399.31,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1494.34,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2592.58,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"minimum":1385.66,"maximum":15618.18,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15618.18,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3428.04,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3688.1,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1666.93,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11406.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1760.51,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3220.41,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7225.27,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1480.75,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1564.58,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3817.4,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":12676.44,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5841.98,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1696.18,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3539.22,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10497.57,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4237.96,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1385.66,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10262.87,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1494.34,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":5030.13,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"minimum":13432.84,"maximum":24437.17,"setting":"outpatient","payers_information":[{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24437.17,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13432.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"minimum":5028.28,"maximum":40567.04,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29311.7,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":40567.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":13183.35,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5028.28,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14045.99,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5282.72,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5064.68,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34367.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"minimum":406.97,"maximum":2267.03,"setting":"outpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2267.03,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":406.97,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 5 Urology and Related Services","code_information":[{"code":"5375","type":"APC"}],"standard_charges":[{"minimum":7705.97,"maximum":7705.97,"setting":"outpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7705.97,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"minimum":1743.75,"maximum":1743.75,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1743.75,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Gynecologic Procedures","code_information":[{"code":"5414","type":"APC"}],"standard_charges":[{"minimum":18218.13,"maximum":18218.13,"setting":"outpatient","payers_information":[{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18218.13,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"minimum":1340.93,"maximum":14850.58,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11150.7,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1498.24,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2041.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12752.05,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3979.38,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1951.84,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12278.63,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1780.09,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1340.93,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14850.58,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1907.35,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3751.76,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"minimum":12.71,"maximum":1838.96,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":536.30,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":733.45,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":212.33,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1377.25,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1738.89,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":502.54,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":393.63,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":437.67,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":458.57,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":70.22,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":307.16,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":1415.7,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12.71,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":309.37,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":396.06,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1395.51,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1434.0,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":553.73,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":527.91,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":1838.96,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1434.26,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":536.05,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":339.02,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"minimum":858.76,"maximum":2688.39,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":858.76,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1487.48,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2688.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"minimum":540.46,"maximum":1245.79,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":540.46,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1245.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"minimum":69.78,"maximum":618.58,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":502.12,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":201.34,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":176.24,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":106.33,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":475.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Connection Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":269.9,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":439.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":103.53,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":151.14,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":382.31,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":509.25,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":101.66,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":418.11,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":99.8,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":69.78,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":618.58,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":173.72,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":108.19,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":198.32,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":513.68,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":384.65,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":215.94,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":95.14,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":435.86,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":513.68,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":102.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":193.80,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"minimum":127.55,"maximum":2585.11,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":800.41,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":362.2,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":478.73,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":182.96,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":912.36,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":840.1,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":178.14,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":323.41,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1079.16,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2585.11,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":174.93,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":127.55,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":171.72,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":194.08,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":1143.34,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":343.79,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":186.17,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":329.32,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":874.78,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1049.20,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":357.58,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":220.73,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":1063.24,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":776.99,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":170.28,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":372.0,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"minimum":379.89,"maximum":2452.32,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1781.31,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":718.89,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":652.62,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":379.89,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2061.56,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2268.96,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":432.76,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":586.52,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2452.32,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1724.32,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":457.41,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":417.16,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":2153.88,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":792.20,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":486.78,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":532.36,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2172.02,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1246.71,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":573.41,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":397.67,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2131.56,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":461.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":670.46,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"minimum":592.01,"maximum":3162.24,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2955.50,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":899.62,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":799.11,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":661.66,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2751.32,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":621.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":873.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1426.71,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":632.64,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":621.03,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":621.03,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":3162.24,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":919.15,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":895.64,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1003.22,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3122.16,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2585.79,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1425.07,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":592.01,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":3129.3,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3116.12,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":845.38,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":861.99,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"minimum":229.57,"maximum":2359.49,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":836.28,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":749.68,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.86,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2218.88,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":550.05,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":725.89,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2096.53,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2359.49,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":704.95,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":692.01,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":751.66,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":694.02,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2348.68,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1406.54,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":639.93,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":693.06,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1639.68,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":229.57,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":407.2,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"minimum":600.94,"maximum":3447.14,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3274.89,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1148.56,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":957.33,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":703.96,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2736.3,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1241.82,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":839.28,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":674.9,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":677.26,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1385.0,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":3447.14,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":709.52,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1070.73,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3279.19,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2274.43,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":927.82,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":600.94,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3258.86,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":672.82,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":846.68,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"minimum":911.6,"maximum":911.6,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":911.6,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Nuclear Medicine and Related Services","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"minimum":450.32,"maximum":4182.76,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1615.83,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":770.63,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3279.48,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1076.08,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":557.44,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":547.21,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":450.32,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":701.43,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2048.38,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":521.64,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4182.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Nuclear Medicine and Related Services","code_information":[{"code":"5592","type":"APC"}],"standard_charges":[{"minimum":6642.5,"maximum":6642.5,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6642.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Nuclear Medicine and Related Services","code_information":[{"code":"5593","type":"APC"}],"standard_charges":[{"minimum":825.55,"maximum":8544.89,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7218.92,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2472.14,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2811.79,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7536.32,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2488.78,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":825.55,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1752.69,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2328.67,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1900.12,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2605.21,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7851.76,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8544.89,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3559.46,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1966.79,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5909.51,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1673.99,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3079.75,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Pathology","code_information":[{"code":"5671","type":"APC"}],"standard_charges":[{"minimum":25.52,"maximum":25.52,"setting":"outpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Pathology","code_information":[{"code":"5673","type":"APC"}],"standard_charges":[{"minimum":43.96,"maximum":5693.18,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1597.95,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":644.8,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4710.91,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3954.9,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":5693.18,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":243.59,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1179.23,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43.96,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4789.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":242.73,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"minimum":2828.95,"maximum":2828.95,"setting":"outpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2828.95,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"minimum":82.63,"maximum":8483.54,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2457.28,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2506.95,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8483.54,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":187.94,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":106.08,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4079.71,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":82.63,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1684.58,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7241.4,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":151.59,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":321.64,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":7158.12,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"minimum":470.76,"maximum":29423.05,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2016.84,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":472.39,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4866.68,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":470.76,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":957.83,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":879.45,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":474.78,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13651.77,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":1562.3,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11625.46,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":473.47,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29423.05,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27316.21,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1965.3,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1319.69,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2119.43,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":821.53,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"minimum":2117.18,"maximum":54714.93,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43640.39,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":15048.54,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16972.16,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2117.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2639.57,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15968.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":35675.42,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16715.67,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9731.59,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":8976.33,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43842.62,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":54714.93,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2503.51,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11901.62,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2626.66,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"minimum":109.08,"maximum":2251.48,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1163.88,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":378.2,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1227.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":183.87,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":334.95,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":256.56,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":290.58,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":407.2,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2251.48,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":109.08,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":302.56,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"minimum":396.23,"maximum":2023.80,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":775.26,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":648.52,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":676.59,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":422.15,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1912.09,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1892.54,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":508.97,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":504.16,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":984.44,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":431.84,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":396.23,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":891.35,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":513.0,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2023.80,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":520.12,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":1366.1,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1583.22,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":707.82,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":638.54,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 3 Diagnostic Tests and Related Services","code_information":[{"code":"5723","type":"APC"}],"standard_charges":[{"minimum":132.85,"maximum":4077.85,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3126.83,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1239.04,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":363.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3372.60,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":132.85,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":860.64,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":716.92,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":525.18,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4077.85,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3262.28,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1209.45,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"minimum":303.9,"maximum":458.8,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":458.8,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":451.32,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":303.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"minimum":39.83,"maximum":1126.99,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":191.32,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":99.51,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":80.18,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":205.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1126.99,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":39.83,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":97.63,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":55.32,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":80.53,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":93.57,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":202.65,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":127.41,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":44.8,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":99.67,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":170.0,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.57,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":186.60,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":58.6,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.55,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":86.71,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":99.53,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"minimum":118.48,"maximum":788.5,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":161.09,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":376.06,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.48,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":220.25,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":192.73,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":189.2,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":265.82,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":493.12,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":251.63,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":295.24,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":278.98,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.5,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":338.66,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":151.16,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":160.63,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":316.35,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":175.72,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":146.98,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":167.71,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 5 Minor Procedures","code_information":[{"code":"5735","type":"APC"}],"standard_charges":[{"minimum":275.61,"maximum":275.61,"setting":"outpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":275.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"minimum":123.82,"maximum":4785.02,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2104.68,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":320.89,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4785.02,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1275.96,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":123.82,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":652.36,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.56,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":406.46,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2048.39,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1249.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2120.4,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"minimum":10703.96,"maximum":42224.22,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27841.23,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":34712.72,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":42224.22,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":20264.69,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":13810.71,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":23142.7,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":10703.96,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"CT and CTA without Contrast Composite","code_information":[{"code":"8005","type":"APC"}],"standard_charges":[{"minimum":972.24,"maximum":4305.89,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1391.28,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4305.89,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1208.32,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":972.24,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1486.45,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"CT and CTA with Contrast Composite","code_information":[{"code":"8006","type":"APC"}],"standard_charges":[{"minimum":750.22,"maximum":13202.44,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7315.18,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1969.38,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1862.69,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5690.59,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7111.91,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":851.7,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2023.74,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6437.27,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":933.26,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1582.7,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":764.48,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":5878.78,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1391.05,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":750.22,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1704.95,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13202.44,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3693.42,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2314.8,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":794.2,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8960.95,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1665.89,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"MRI and MRA without Contrast Composite","code_information":[{"code":"8007","type":"APC"}],"standard_charges":[{"minimum":428.86,"maximum":11973.04,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1559.92,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4551.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1287.62,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":673.52,"methodology":"other"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1092.74,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":452.25,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11973.04,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":428.86,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1247.23,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"MRI and MRA with Contrast Composite","code_information":[{"code":"8008","type":"APC"}],"standard_charges":[{"minimum":703.91,"maximum":32114.98,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":32114.98,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":703.91,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5999.87,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5666.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Comprehensive Observation Services","code_information":[{"code":"8011","type":"APC"}],"standard_charges":[{"minimum":1890.7,"maximum":15589.25,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4456.72,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":6249.31,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13147.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9279.07,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7176.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4334.22,"methodology":"percent of total billed charges"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2692.87,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3179.87,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3133.34,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3285.36,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2393.25,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":3463.66,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15589.25,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":7579.39,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10192.68,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1890.7,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":4295.32,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Rabies vaccine, im","code_information":[{"code":"9139","type":"APC"}],"standard_charges":[{"minimum":2717.87,"maximum":2717.87,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2717.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inj, durolane 1 mg","code_information":[{"code":"9174","type":"APC"}],"standard_charges":[{"minimum":69.13,"maximum":2481.47,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":2481.47,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":69.13,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Leuprolide acetate suspnsion","code_information":[{"code":"9217","type":"APC"}],"standard_charges":[{"minimum":370.45,"maximum":776.02,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":776.02,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":607.16,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":370.45,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Inj, bupivacaine, nos, 0.5mg","code_information":[{"code":"9290","type":"APC"}],"standard_charges":[{"minimum":41045.17,"maximum":41045.17,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":41045.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Daratumumab, hyaluronidase","code_information":[{"code":"9378","type":"APC"}],"standard_charges":[{"minimum":117986.96,"maximum":117986.96,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":117986.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Platelets pheresis path redu","code_information":[{"code":"9536","type":"APC"}],"standard_charges":[{"minimum":5621.58,"maximum":5621.58,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5621.58,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"minimum":62.18,"maximum":298.29,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":212.74,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":75.02,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":66.86,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":91.80,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":283.63,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":298.29,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":74.36,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":87.78,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":237.08,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":285.61,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":81.75,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":89.10,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":96.55,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":62.53,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":261.56,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":72.54,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":62.18,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":92.66,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":287.10,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":273.19,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":87.12,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":81.87,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":77.72,"methodology":"percent of total billed charges"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":285.95,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":291.28,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":83.84,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":65.56,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"minimum":134.79,"maximum":2638.36,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2638.36,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":651.0,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":898.62,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":637.28,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1695.25,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":369.33,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":839.69,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":626.07,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1266.46,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":454.79,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":803.4,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":598.13,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":2512.34,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1052.76,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":134.79,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":903.75,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2073.32,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1618.76,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":1144.1,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1069.15,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2444.8,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":922.35,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":755.98,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"minimum":86.63,"maximum":297.35,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":248.04,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":88.4,"methodology":"percent of total billed charges"},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":99.23,"methodology":"percent of total billed charges"},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":111.53,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":254.29,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":254.28,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":128.26,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":86.63,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Traditional","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":254.28,"methodology":"other"},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":109.4,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.35,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":112.96,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":96.0,"estimated_amount":250.91,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.03,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":134.04,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":86.63,"methodology":"percent of total billed charges"},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":115.78,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":113.9,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":91.74,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":106.42,"methodology":"other"},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":95.0,"estimated_amount":297.35,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":296.1,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":116.13,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":164.75,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"minimum":1317.33,"maximum":2888.98,"setting":"outpatient","payers_information":[{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2888.98,"methodology":"other"},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1317.33,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"minimum":9.15,"maximum":9245.92,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":42.95,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9245.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9.15,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":850.16,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":35.05,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":132.63,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Not Recognized by OPPS","code_information":[{"code":"N905","type":"APC"}],"standard_charges":[{"minimum":53.94,"maximum":719.7,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":53.94,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":82.29,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":31.0,"estimated_amount":719.7,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]}],"modifier_information":[{"description":"Bilateral Procedure","code":"50","modifier_payer_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Blue Connection Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medigold","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Drug amount discarded/not administered to any patient","code":"JW","modifier_payer_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allwell","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Amerihealth","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Blue Access HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Blue Connection Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Fed Govt Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathway Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health Plan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medigold","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Ohio Health Choice","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."}]}]}