{"hospital_name": "Foundation Bariatric Hospital of San Antonio, LLC", "last_updated_on": "2026-04-01", "version": "3.0.0", "pid": "1549986234", "rid": "9319", "location_name": ["Foundation Surgical Hospital of San Antonio"], "hospital_address": ["9522 Huebner Rd, San Antonio, TX 78240"], "type_2_npi": ["1932284411"], "license_information": {"license_number": "008521", "state": "TX"}, "attestation": {"attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Geoffrey Vines"}, "standard_charge_information": [{"description": "1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED", "code_information": [{"code": "82652", "type": "CPT"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 32.73, "maximum": 97.41, "gross_charge": 402.0, "discounted_cash": 241.2, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of 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"payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 63.2, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 63.2, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 54.8, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 123.2, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "1ST HOSP IP/OBS HIGH 75", "code_information": [{"code": "99223", "type": "CPT"}], "standard_charges": [{"minimum": 281.43, "maximum": 632.69, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 324.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 324.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 281.43, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 632.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "1ST HOSP IP/OBS MODERATE 55", "code_information": [{"code": "99222", "type": "CPT"}], "standard_charges": [{"minimum": 190.58, "maximum": 428.46, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 219.79, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 219.79, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 190.58, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 428.46, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "1ST HOSP IP/OBS SF/LOW 40", "code_information": [{"code": "99221", "type": "CPT"}], "standard_charges": [{"minimum": 141.21, "maximum": 317.46, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 162.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 162.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 141.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 317.46, "methodology": "fee schedule"}], "billing_class": 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1508.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ABL1 GENE", "code_information": [{"code": "81170", "type": "CPT"}], "standard_charges": [{"minimum": 255.0, "maximum": 759.0, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 327.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 720.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 315.0, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 255.0, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 285.0, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": 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"type": "MS-DRG"}], "standard_charges": [{"minimum": 7540.93, "maximum": 17236.42, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 17236.42, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 7540.93, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "APPL HALO CRANIAL 6+PINS", "code_information": [{"code": "20664", "type": "CPT"}], "standard_charges": [{"minimum": 784.76, "maximum": 1752.02, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 866.88, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 784.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 821.26, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1752.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "APPL MODALITY 1+ESTIM EA 15", "code_information": [{"code": "97032", "type": "CPT"}], "standard_charges": [{"minimum": 20.74, "maximum": 46.63, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 23.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 23.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 20.74, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 46.63, "methodology": "fee 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{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 54.36, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 23.78, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 19.25, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 21.52, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 57.3, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY GALACTOSE TRANSFERASE", "code_information": [{"code": "82775", "type": "CPT"}], "standard_charges": [{"minimum": 17.91, "maximum": 53.31, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", 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"standard_charge_dollar": 12.26, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 32.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF ADP & AMP", "code_information": [{"code": "82030", "type": "CPT"}], "standard_charges": [{"minimum": 21.93, "maximum": 65.27, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 28.12, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 61.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 27.09, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 21.93, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 24.51, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 65.27, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF ALDOLASE", "code_information": [{"code": "82085", "type": "CPT"}], "standard_charges": [{"minimum": 8.25, "maximum": 24.57, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 10.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 23.3, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 10.2, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 8.25, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 9.22, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 24.57, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF ALDOSTERONE", "code_information": [{"code": "82088", "type": "CPT"}], "standard_charges": [{"minimum": 34.64, "maximum": 103.1, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 44.42, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 97.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 42.79, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 34.64, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 38.71, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 103.1, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF ALUMINUM", "code_information": [{"code": "82108", "type": "CPT"}], "standard_charges": [{"minimum": 21.66, "maximum": 64.46, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 27.77, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 61.15, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 26.75, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 21.66, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 24.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 64.46, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF AMIKACIN", "code_information": [{"code": "80150", "type": "CPT"}], "standard_charges": [{"minimum": 12.82, "maximum": 38.15, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 16.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 36.19, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 15.83, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 12.82, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 14.33, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 38.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF ANDROSTENEDIONE", "code_information": [{"code": "82157", "type": "CPT"}], "standard_charges": [{"minimum": 24.89, "maximum": 74.08, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 31.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 70.27, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": 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"standard_charge_dollar": 49.25, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 21.55, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 17.44, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 19.49, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 51.92, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF APOLIPOPROTEIN", "code_information": [{"code": "82172", "type": "CPT"}], "standard_charges": [{"minimum": 17.93, "maximum": 53.36, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 22.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 50.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 22.14, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 17.93, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 20.04, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 53.36, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF ARSENIC", "code_information": [{"code": "82175", "type": "CPT"}], "standard_charges": [{"minimum": 16.12, "maximum": 47.99, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 20.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 45.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 19.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 16.12, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 18.02, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 47.99, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF B HEXOSAMINIDASE EA", "code_information": [{"code": "83080", "type": "CPT"}], "standard_charges": [{"minimum": 14.34, "maximum": 42.68, "setting": "outpatient", "payers_information": 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42.68, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 18.39, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 40.49, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.71, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 14.34, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 16.03, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 42.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF BLOOD FATTY ACIDS", "code_information": [{"code": "82725", "type": "CPT"}], "standard_charges": [{"minimum": 15.95, "maximum": 47.49, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 20.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 45.05, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 19.71, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 15.95, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 17.83, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 47.49, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF BLOOD LIPOPROTEIN", "code_information": [{"code": "83719", "type": "CPT"}], "standard_charges": [{"minimum": 10.84, "maximum": 32.26, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 13.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 30.6, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 13.39, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 10.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 12.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 32.26, "methodology": "fee schedule"}], 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{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 51.55, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 22.55, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 18.26, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 20.41, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 54.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF RBC PG6D ENZYME", "code_information": [{"code": "84085", "type": "CPT"}], "standard_charges": [{"minimum": 8.02, "maximum": 23.88, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", 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"methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 46.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF SWEAT SODIUM", "code_information": [{"code": "84302", "type": "CPT"}], "standard_charges": [{"minimum": 4.13, "maximum": 12.3, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 5.3, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 11.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.1, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4.13, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", 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{"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 13.43, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 35.77, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF THIOCYANATE", "code_information": [{"code": "84430", "type": "CPT"}], "standard_charges": [{"minimum": 9.89, "maximum": 29.42, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 12.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 27.91, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 12.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", 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{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 122.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 53.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 43.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 48.32, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 128.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF TYROSINE", "code_information": [{"code": "84510", "type": "CPT"}], "standard_charges": [{"minimum": 9.04, "maximum": 26.89, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", 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"methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 85.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF VIP", "code_information": [{"code": "84586", "type": "CPT"}], "standard_charges": [{"minimum": 30.03, "maximum": 89.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 38.51, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 84.79, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 37.1, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 30.03, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 33.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 89.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF VITAMIN B-2", "code_information": [{"code": "84252", "type": "CPT"}], "standard_charges": [{"minimum": 17.2, "maximum": 51.21, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 22.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 48.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 21.25, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 17.2, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 19.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 51.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OF VOLATILES", "code_information": [{"code": "84600", "type": "CPT"}], "standard_charges": [{"minimum": 14.54, "maximum": 43.29, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 18.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 41.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.97, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 14.54, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 16.25, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 43.29, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY OTHER FLUID CHLORIDES", "code_information": [{"code": "82438", "type": "CPT"}], "standard_charges": [{"minimum": 4.25, "maximum": 12.65, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 5.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.25, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4.25, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4.75, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 12.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY PH BODY FLUID NOS", "code_information": [{"code": "83986", "type": "CPT"}], "standard_charges": [{"minimum": 3.04, "maximum": 9.06, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 3.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8.59, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 3.04, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 3.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY PHOSPHATIDYLGLYCEROL", "code_information": [{"code": "84081", "type": "CPT"}], "standard_charges": [{"minimum": 14.04, "maximum": 41.8, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 18.01, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 39.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.35, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 14.04, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 15.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 41.8, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY PHOSPHOHEXOSE ENZYMES", "code_information": [{"code": "84087", "type": "CPT"}], "standard_charges": [{"minimum": 9.12, "maximum": 27.15, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 11.7, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 25.75, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 11.27, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 9.12, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 10.19, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 27.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY PROSTATE PHOSPHATASE", "code_information": [{"code": "84066", "type": "CPT"}], "standard_charges": [{"minimum": 8.21, "maximum": 24.44, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 10.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 23.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 10.14, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 8.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 9.18, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 24.44, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY RBC CHOLINESTERASE", "code_information": [{"code": "82482", "type": "CPT"}], "standard_charges": [{"minimum": 8.34, "maximum": 24.82, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 10.69, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 23.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 10.3, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 8.34, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 9.32, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 24.82, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY RBC GLUTATHIONE", "code_information": [{"code": "82979", "type": "CPT"}], "standard_charges": [{"minimum": 8.02, "maximum": 23.88, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 10.29, "methodology": "fee 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"standard_charge_dollar": 15.64, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 34.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 15.07, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 12.2, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 13.63, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 36.31, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ASSAY SERUM CHOLINESTERASE", "code_information": [{"code": "82480", "type": "CPT"}], "standard_charges": [{"minimum": 6.69, "maximum": 19.91, "setting": "outpatient", "payers_information": [{"payer_name": 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{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 11629.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 2725.05, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5088.03, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 3952.72, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4136.57, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 8824.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CANTHARIDIN TOP, APPLICATOR", "code_information": [{"code": "C9164", "type": "HCPCS"}], "standard_charges": [{"minimum": 685.62, 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 6623.8, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 5144.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 5383.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 11485.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PROCEDURE OR MAGNUSON TYPE OPERATION", "code_information": [{"code": "23450", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 3391.14, "maximum": 15140.11, "gross_charge": 42360.0, "discounted_cash": 25416.0, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": 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"methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CHANGE OF BLADDER TUBE", "code_information": [{"code": "51705", "type": "CPT"}], "standard_charges": [{"minimum": 51.77, "maximum": 523.03, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 58.28, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 523.03, "methodology": "fee schedule"}, {"payer_name": "Community First", 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{"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 335.48, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CHEMICAL PEEL NONFACIAL", "code_information": [{"code": "15792", "type": "CPT"}], "standard_charges": [{"minimum": 274.78, "maximum": 1329.14, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 303.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1329.14, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 581.5, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 274.78, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 287.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 613.46, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CHEMICAL PEEL NONFACIAL", "code_information": [{"code": "15793", "type": "CPT"}], "standard_charges": [{"minimum": 274.78, "maximum": 843.86, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 303.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 843.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 369.19, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 274.78, "methodology": "fee schedule"}, 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 65.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 95.54, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 82.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 186.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CHEMO IA INFUSE EACH ADDL HR", "code_information": [{"code": "96423", "type": "CPT"}], "standard_charges": [{"minimum": 43.98, "maximum": 248.65, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 127.55, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", 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"standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE", "code_information": [{"code": "52281", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 652.8, "maximum": 4310.5, "gross_charge": 15159.0, "discounted_cash": 9095.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1682.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4310.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 652.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1885.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA", "code_information": [{"code": "52260", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 652.8, "maximum": 4310.5, "gross_charge": 15159.0, "discounted_cash": 9095.4, 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"billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)", "code_information": [{"code": "52240", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1689.43, "maximum": 10950.46, "gross_charge": 18949.0, "discounted_cash": 11369.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4020.04, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 10950.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1689.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4790.82, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 3639.19, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 3808.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 8124.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)", "code_information": [{"code": "52235", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1142.9, "maximum": 7377.74, "gross_charge": 15159.0, "discounted_cash": 9095.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2867.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": 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"type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1142.9, "maximum": 7377.74, "gross_charge": 15159.0, "discounted_cash": 9095.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2867.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7377.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1142.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3227.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2595.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2716.69, "methodology": "fee 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3227.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)", "code_information": [{"code": "52332", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1142.9, "maximum": 7377.74, "gross_charge": 21846.0, "discounted_cash": 13107.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", 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MALE", "code_information": [{"code": "52275", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 652.8, "maximum": 4310.5, "gross_charge": 11048.0, "discounted_cash": 6628.8, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1682.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4310.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 652.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1885.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE", "code_information": [{"code": "52310", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 652.8, "maximum": 4310.5, "gross_charge": 21846.0, "discounted_cash": 13107.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1682.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4310.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 652.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1885.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE", "code_information": [{"code": "52283", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 652.8, "maximum": 4310.5, "gross_charge": 8476.0, "discounted_cash": 5085.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1682.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4310.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 652.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1885.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;", "code_information": [{"code": "52005", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 652.8, "maximum": 4310.5, "gross_charge": 21846.0, "discounted_cash": 13107.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1682.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4310.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 652.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1885.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1523.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1594.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3401.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS", "code_information": [{"code": "52007", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1142.9, "maximum": 7377.74, "gross_charge": 15144.0, "discounted_cash": 9086.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2867.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7377.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1142.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3227.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2595.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2716.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5795.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC", "code_information": [{"code": "52351", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1142.9, "maximum": 7377.74, "gross_charge": 15159.0, "discounted_cash": 9095.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2867.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7377.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1142.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3227.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2595.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2716.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5795.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION", "code_information": [{"code": "52354", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1689.43, "maximum": 10950.46, "gross_charge": 15159.0, "discounted_cash": 9095.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4020.04, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 10950.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1689.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4790.82, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 3639.19, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 3808.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 8124.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)", "code_information": [{"code": "52353", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1689.43, "maximum": 10950.46, "gross_charge": 20852.0, "discounted_cash": 12511.2, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4020.04, "methodology": "fee schedule"}, {"payer_name": 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{"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 24.89, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 27.82, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 74.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DEOXYRIBONUCLEASE ANTIBODY", "code_information": [{"code": "86215", "type": "CPT"}, {"code": "302", "type": "RC"}], "standard_charges": [{"minimum": 11.26, "maximum": 33.52, "gross_charge": 146.0, "discounted_cash": 87.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 14.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 31.8, "methodology": "fee schedule"}, 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"standard_charge_dollar": 1547.42, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3301.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DESTRUCTION BY NEUROLYTIC AGENT, CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MONITORING", "code_information": [{"code": "64680", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 340.77, "maximum": 1928.95, "gross_charge": 9878.0, "discounted_cash": 5926.8, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 771.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1928.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 340.77, "methodology": "fee schedule"}, {"payer_name": 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"billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E0302", "type": "HCPCS"}], "standard_charges": [{"minimum": 584.64, "maximum": 1336.32, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1336.32, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 584.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E0303", "type": "HCPCS"}], "standard_charges": [{"minimum": 205.13, "maximum": 468.86, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 468.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 205.13, "methodology": "fee schedule"}], "billing_class": 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{"description": "DME POS", "code_information": [{"code": "E0310", "type": "HCPCS"}], "standard_charges": [{"minimum": 136.11, "maximum": 311.11, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 311.11, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 136.11, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E0316", "type": "HCPCS"}], "standard_charges": [{"minimum": 238.29, "maximum": 544.66, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 544.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 238.29, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"description": "DME POS", "code_information": [{"code": "E0617", "type": "HCPCS"}], "standard_charges": [{"minimum": 435.58, "maximum": 995.62, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 995.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 435.58, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E0618", "type": "HCPCS"}], "standard_charges": [{"minimum": 341.42, "maximum": 780.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 780.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 341.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1287.37, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E0692", "type": "HCPCS"}], "standard_charges": [{"minimum": 1616.6, "maximum": 3695.09, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3695.09, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1616.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E0693", "type": "HCPCS"}], "standard_charges": [{"minimum": 1992.81, "maximum": 4554.98, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4554.98, "methodology": "fee schedule"}, {"payer_name": 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 188.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E1295", "type": "HCPCS"}], "standard_charges": [{"minimum": 174.02, "maximum": 397.75, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 397.75, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 174.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "E1296", "type": "HCPCS"}], "standard_charges": [{"minimum": 598.72, "maximum": 1368.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1368.5, "methodology": "fee schedule"}, {"payer_name": 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{"description": "DME POS", "code_information": [{"code": "K0042", "type": "HCPCS"}], "standard_charges": [{"minimum": 38.58, "maximum": 88.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 88.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 38.58, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "K0043", "type": "HCPCS"}], "standard_charges": [{"minimum": 23.81, "maximum": 54.43, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 54.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 23.81, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", 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{"description": "DME POS", "code_information": [{"code": "L1200", "type": "HCPCS"}], "standard_charges": [{"minimum": 2081.65, "maximum": 4758.05, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4758.05, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2081.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L1210", "type": "HCPCS"}], "standard_charges": [{"minimum": 302.26, "maximum": 690.89, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 690.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 302.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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"L1260", "type": "HCPCS"}], "standard_charges": [{"minimum": 94.54, "maximum": 216.1, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 216.1, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 94.54, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L1270", "type": "HCPCS"}], "standard_charges": [{"minimum": 90.91, "maximum": 207.79, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 207.79, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 90.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L1280", "type": "HCPCS"}], 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{"description": "DME POS", "code_information": [{"code": "L1990", "type": "HCPCS"}], "standard_charges": [{"minimum": 514.93, "maximum": 1176.98, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1176.98, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 514.93, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L2000", "type": "HCPCS"}], "standard_charges": [{"minimum": 1171.71, "maximum": 2678.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2678.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1171.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": 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{"description": "DME POS", "code_information": [{"code": "L2425", "type": "HCPCS"}], "standard_charges": [{"minimum": 178.05, "maximum": 406.97, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 406.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 178.05, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L2430", "type": "HCPCS"}], "standard_charges": [{"minimum": 178.05, "maximum": 406.97, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 406.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 178.05, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"description": "DME POS", "code_information": [{"code": "L5698", "type": "HCPCS"}], "standard_charges": [{"minimum": 147.28, "maximum": 336.65, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 336.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 147.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L5699", "type": "HCPCS"}], "standard_charges": [{"minimum": 229.47, "maximum": 524.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 524.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 229.47, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", 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{"description": "DME POS", "code_information": [{"code": "L8310", "type": "HCPCS"}], "standard_charges": [{"minimum": 163.92, "maximum": 374.66, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 374.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 163.92, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L8320", "type": "HCPCS"}], "standard_charges": [{"minimum": 75.68, "maximum": 172.99, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 172.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 75.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 891.3, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L8606", "type": "HCPCS"}], "standard_charges": [{"minimum": 270.82, "maximum": 619.01, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 619.01, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 270.82, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L8607", "type": "HCPCS"}], "standard_charges": [{"minimum": 53.39, "maximum": 122.04, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 122.04, "methodology": "fee schedule"}, {"payer_name": "Community 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{"description": "DME POS", "code_information": [{"code": "L8641", "type": "HCPCS"}], "standard_charges": [{"minimum": 430.82, "maximum": 984.72, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 984.72, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 430.82, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "L8642", "type": "HCPCS"}], "standard_charges": [{"minimum": 358.23, "maximum": 818.81, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 818.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 358.23, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"description": "DME POS", "code_information": [{"code": "Q0477", "type": "HCPCS"}], "standard_charges": [{"minimum": 965.52, "maximum": 2206.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2206.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 965.52, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "Q0478", "type": "HCPCS"}], "standard_charges": [{"minimum": 228.69, "maximum": 522.72, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 522.72, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 228.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 82.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2100", "type": "HCPCS"}], "standard_charges": [{"minimum": 59.17, "maximum": 135.24, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 135.24, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 59.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2101", "type": "HCPCS"}], "standard_charges": [{"minimum": 67.74, "maximum": 154.82, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 154.82, "methodology": "fee schedule"}, {"payer_name": "Community 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{"description": "DME POS", "code_information": [{"code": "V2114", "type": "HCPCS"}], "standard_charges": [{"minimum": 111.54, "maximum": 254.95, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 254.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 111.54, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2115", "type": "HCPCS"}], "standard_charges": [{"minimum": 121.38, "maximum": 277.44, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 277.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 121.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 88.31, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2305", "type": "HCPCS"}], "standard_charges": [{"minimum": 109.66, "maximum": 250.66, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 250.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 109.66, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2306", "type": "HCPCS"}], "standard_charges": [{"minimum": 131.55, "maximum": 300.7, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 300.7, "methodology": "fee schedule"}, {"payer_name": "Community 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"billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2319", "type": "HCPCS"}], "standard_charges": [{"minimum": 69.0, "maximum": 157.7, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 157.7, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 69.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2320", "type": "HCPCS"}], "standard_charges": [{"minimum": 85.96, "maximum": 196.49, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 196.49, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 85.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2321", "type": "HCPCS"}], "standard_charges": [{"minimum": 146.42, "maximum": 334.68, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 334.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 146.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2410", "type": "HCPCS"}], "standard_charges": [{"minimum": 130.17, "maximum": 297.53, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 297.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 130.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 25.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2745", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.84, "maximum": 38.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 38.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 16.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "DME POS", "code_information": [{"code": "V2750", "type": "HCPCS"}], "standard_charges": [{"minimum": 31.32, "maximum": 71.59, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 71.59, "methodology": "fee schedule"}, {"payer_name": "Community First", 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"billing_class": "facility"}]}, {"description": "DMPK GENE CHARAC ALLELES", "code_information": [{"code": "81239", "type": "CPT"}], "standard_charges": [{"minimum": 233.61, "maximum": 695.32, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 299.56, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 659.59, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 288.57, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 233.61, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 261.09, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", 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"RC"}], "standard_charges": [{"minimum": 698.3, "maximum": 4945.34, "gross_charge": 15144.0, "discounted_cash": 9086.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1838.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4945.34, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 698.3, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2163.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1664.27, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1741.68, "methodology": "fee schedule"}, {"payer_name": "blue cross blue 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"standard_charge_dollar": 2980.97, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2252.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2357.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5029.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, EXTENDING BENEATH SUBCUTANEOUS TISSUES AND/OR INTO PHARYNX", "code_information": [{"code": "42815", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "gross_charge": 25020.0, "discounted_cash": 15012.0, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 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{"description": "Extensive Third Degree Burns Without Skin Graft, Major", "code_information": [{"code": "843.3", "type": "APR-DRG"}], "standard_charges": [{"minimum": 6247.39, "maximum": 6247.39, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 6247.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Extensive Third Degree Burns Without Skin Graft, Minor", "code_information": [{"code": "843.1", "type": "APR-DRG"}], "standard_charges": [{"minimum": 2796.74, "maximum": 2796.74, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 2796.74, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Extensive Third Degree Burns Without Skin Graft, Moderate", "code_information": [{"code": "843.2", "type": "APR-DRG"}], "standard_charges": [{"minimum": 5193.42, "maximum": 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"standard_charge_dollar": 972.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 2075.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACE BONE GRAFT", "code_information": [{"code": "21210", "type": "CPT"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4608.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12393.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACIAL MOULAGE COMPLETE", "code_information": [{"code": "D5912", "type": "HCPCS"}], "standard_charges": [{"minimum": 815.21, "maximum": 1863.34, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1863.34, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 815.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACIAL MOULAGE SECTIONAL", "code_information": 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"standard_charge_dollar": 290.61, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 37.02, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 32.1, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 72.16, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACILITY SVS DENTAL REHAB", "code_information": [{"code": "G0330", "type": "HCPCS"}], "standard_charges": [{"minimum": 2359.73, "maximum": 6813.65, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2721.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6813.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2980.97, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2721.44, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2359.73, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5305.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR INHIBITOR TEST", "code_information": [{"code": "85335", "type": "CPT"}], "standard_charges": [{"minimum": 10.94, "maximum": 32.56, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 14.03, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 30.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 13.51, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 10.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 12.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 32.56, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX ALPROLIX RECOMB", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7201", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.37, "maximum": 7.7, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7.7, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.37, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX COMPLEX", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7194", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.56, "maximum": 3.58, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.56, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX IDELVION INJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7202", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.8, "maximum": 10.97, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 10.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4.8, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX NON-RECOMBINANT", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7193", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.28, "maximum": 2.93, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.93, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX RECOMB GLY REBINYN", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7203", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.28, "maximum": 9.79, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 9.79, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX RECOMBINAN RIXUBIS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7200", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.5, "maximum": 3.43, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.5, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FACTOR IX RECOMBINANT NOS", 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"standard_charge_dollar": 5144.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 5383.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 11485.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FUSION OF FACIAL/OTHER NERVE", "code_information": [{"code": "64866", "type": "CPT"}], "standard_charges": [{"minimum": 1140.26, "maximum": 2545.69, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1259.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1140.26, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1193.29, "methodology": 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{"description": "FUSION OF FINGER JOINTS", "code_information": [{"code": "C7506", "type": "HCPCS"}], "standard_charges": [{"minimum": 929.69, "maximum": 2075.6, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1026.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 929.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 972.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 2075.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "FUSION OF FOOT BONES", "code_information": [{"code": "28705", "type": "CPT"}], "standard_charges": [{"minimum": 9894.93, "maximum": 39439.39, "setting": "outpatient", 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{"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 136.33, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 363.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "IMMUNOTHERAPY INJECTIONS", "code_information": [{"code": "95117", "type": "CPT"}], "standard_charges": [{"minimum": 43.98, "maximum": 117.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 60.21, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 100.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 43.98, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 60.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 52.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 117.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "IMMUNOTHERAPY ONE INJECTION", "code_information": [{"code": "95115", "type": "CPT"}], "standard_charges": [{"minimum": 43.98, "maximum": 117.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 60.21, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 100.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 43.98, "methodology": "fee schedule"}, {"payer_name": 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INCISIONAL OR VENTRAL HERNIA REPAIR)", "code_information": [{"code": "49568", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 5267.0, "discounted_cash": 3160.2, "setting": "both", "billing_class": "facility"}]}, {"description": "IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NON-PROGRAMMABLE PUMP", "code_information": [{"code": "62361", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 10993.86, "maximum": 37742.66, "gross_charge": 104252.0, "discounted_cash": 62551.2, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 15690.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 37742.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 10993.86, "methodology": "fee 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"billing_class": "facility"}]}, {"description": "IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; SUBCUTANEOUS RESERVOIR", "code_information": [{"code": "62360", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 11274.86, "maximum": 37742.66, "gross_charge": 24510.0, "discounted_cash": 14706.0, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 15690.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 37742.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 11274.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 16512.42, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": 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{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 14097.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 2890.51, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 6167.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4737.75, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4958.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 10577.3, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "IMPLT ANT SGM IO NBIO RX SYS", "code_information": [{"code": "660T", "type": "CPT"}], "standard_charges": [{"minimum": 929.69, 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"plan_name": "HMO", "standard_charge_dollar": 26206.87, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 55907.98, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "IMPLTJ NTRSTRML CRNL RNG SEG", "code_information": [{"code": "65785", "type": "CPT"}], "standard_charges": [{"minimum": 1533.49, "maximum": 8604.53, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1744.05, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8604.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1533.49, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3764.48, "methodology": "fee 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"methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1819.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3881.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INCISION OF JAW JOINT", "code_information": [{"code": "21010", "type": "CPT"}], "standard_charges": [{"minimum": 886.62, "maximum": 6813.65, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2488.33, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6813.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 886.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2980.97, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2252.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2357.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5029.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INCISION OF JAW NERVE", "code_information": [{"code": "64738", "type": "CPT"}], "standard_charges": [{"minimum": 659.94, "maximum": 4086.1, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1633.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4086.1, "methodology": "fee 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{"description": "INCISION OF LYMPH CHANNELS", "code_information": [{"code": "38308", "type": "CPT"}], "standard_charges": [{"minimum": 963.66, "maximum": 8066.76, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2878.07, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8066.76, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 963.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3529.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2605.41, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2726.6, "methodology": 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{"description": "INCISION OF PALM TENDON", "code_information": [{"code": "26450", "type": "CPT"}], "standard_charges": [{"minimum": 1088.27, "maximum": 6850.1, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2600.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6850.1, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1088.27, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2996.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2354.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2463.71, "methodology": 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{"description": "INCISION OF RECTAL ABSCESS", "code_information": [{"code": "46045", "type": "CPT"}], "standard_charges": [{"minimum": 939.93, "maximum": 5942.11, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2226.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5942.11, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 939.93, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2599.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2015.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2109.76, "methodology": 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"Advantage", "standard_charge_dollar": 2015.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2109.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 4500.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INCISION OF SMALL BOWEL", "code_information": [{"code": "44010", "type": "CPT"}], "standard_charges": [{"minimum": 772.99, "maximum": 1725.73, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 853.88, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 772.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 808.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1725.73, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO OSTEOMYELITIS); DEEP OR COMPLICATED", "code_information": [{"code": "20005", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 9774.0, "discounted_cash": 5864.4, "setting": "both", "billing_class": "facility"}]}, {"description": "INCISION OF SPERM DUCT", "code_information": [{"code": "55200", "type": "CPT"}], "standard_charges": [{"minimum": 2595.94, "maximum": 7377.74, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2867.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7377.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3227.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2595.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2716.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5795.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INCISION OF STOMACH NERVES", "code_information": [{"code": "64755", "type": "CPT"}], "standard_charges": [{"minimum": 815.44, "maximum": 1820.52, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 900.78, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", 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"methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 423.7, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 185.37, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 150.27, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 157.26, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 335.48, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INITIAT MED ASSIST TX IN ER", "code_information": [{"code": "G2213", "type": "HCPCS"}], "standard_charges": [{"minimum": 93.31, "maximum": 209.78, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 58.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ANDEXXA, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7169", "type": "HCPCS"}], "standard_charges": [{"minimum": 128.61, "maximum": 293.98, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 293.98, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 128.61, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ANIFROLUMAB-FNIA 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0491", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.7, "maximum": 38.16, "setting": "outpatient", "payers_information": [{"payer_name": "Community 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{"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9037", "type": "HCPCS"}], "standard_charges": [{"minimum": 45.45, "maximum": 103.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 103.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 45.45, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ BENDAMUSTINE, BAXTER 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9059", "type": "HCPCS"}], "standard_charges": [{"minimum": 20.19, "maximum": 46.15, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 46.15, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 20.19, "methodology": "fee 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Advantage", "standard_charge_dollar": 200.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ BUPRENORPH (BRIXADI) 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0576", "type": "HCPCS"}], "standard_charges": [{"minimum": 12.47, "maximum": 28.51, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 28.51, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 12.47, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CEFAZOLIN SODIUM, BAXTER", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0689", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.2, "maximum": 2.74, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.2, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CEFTOLOZANE TAZOBACTAM", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0695", "type": "HCPCS"}], "standard_charges": [{"minimum": 7.16, "maximum": 16.37, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 16.37, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 7.16, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CLADRIBINE PER 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9065", "type": "HCPCS"}], "standard_charges": [{"minimum": 15.33, "maximum": 35.04, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 35.04, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 15.33, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CRIZANLIZUMAB-TMCA 5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0791", "type": "HCPCS"}], "standard_charges": [{"minimum": 123.51, "maximum": 282.31, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 282.31, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 123.51, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CROTALIDAE IM F(AB')2 EQ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0841", "type": "HCPCS"}], "standard_charges": [{"minimum": 886.32, "maximum": 2025.86, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2025.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 886.32, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CUTAQUIG 100 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1551", "type": "HCPCS"}], "standard_charges": [{"minimum": 13.49, "maximum": 30.84, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 30.84, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 13.49, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CUVITRU, 100 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1555", "type": "HCPCS"}], "standard_charges": [{"minimum": 15.48, "maximum": 35.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 35.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 15.48, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CYCLOPHOS DR.REDDY'S 5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9072", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.65, "maximum": 8.35, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8.35, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CYCLOPHOSPHAMD AUROMEDIC", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9071", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.74, "maximum": 3.98, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.98, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.74, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DAUNORUBICIN, CYTARABINE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9153", "type": "HCPCS"}], "standard_charges": [{"minimum": 225.21, "maximum": 514.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 514.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 225.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DAXIBOTULINUMTOXINA-LANM", "code_information": [{"code": "C9160", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.33, "maximum": 9.89, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 9.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4.33, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DELANDISTROGENE MOX ROKL", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1413", "type": "HCPCS"}], "standard_charges": [{"minimum": 3202901.18, "maximum": 7320916.99, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7320916.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3202901.18, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DESMOPRESSIN ACETATE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2597", "type": "HCPCS"}], "standard_charges": [{"minimum": 6.15, "maximum": 14.06, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 14.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 6.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DUPUYTREN CORD W/ENZYME", "code_information": [{"code": "20527", "type": "CPT"}], "standard_charges": [{"minimum": 38.48, "maximum": 626.81, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 42.85, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 38.48, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 274.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 38.79, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 40.6, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 86.61, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ EFGART-ALFA 2MG HYA-QVFC", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9334", "type": "HCPCS"}], "standard_charges": [{"minimum": 31.32, "maximum": 71.59, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 71.59, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 31.32, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ EFGARTIGIMOD 2MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9332", "type": "HCPCS"}], "standard_charges": [{"minimum": 31.17, "maximum": 71.26, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 71.26, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 31.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ EFLAPEGRASTIM-XNST 0.1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1449", "type": "HCPCS"}], "standard_charges": [{"minimum": 28.84, "maximum": 65.93, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 65.93, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 28.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ENFORT VEDO-EJFV 0.25MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9177", "type": "HCPCS"}], "standard_charges": [{"minimum": 34.04, "maximum": 77.81, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 77.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 34.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ EPCORITAMAB-BYSP 0.16 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9321", "type": "HCPCS"}], "standard_charges": [{"minimum": 52.28, "maximum": 119.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 119.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 52.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ESMOLOL HCL WG CRIT CARE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1806", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.44, "maximum": 1.01, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.01, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.44, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ESTROGEN CONJUGATE 25 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1410", "type": "HCPCS"}], "standard_charges": [{"minimum": 361.63, "maximum": 826.58, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 826.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 361.63, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FENSOLVI 0.25 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1951", "type": "HCPCS"}], "standard_charges": [{"minimum": 128.1, "maximum": 292.8, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 292.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 128.1, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FERRIC CARBOXYMALTOS 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1439", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.11, "maximum": 2.54, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.11, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FILGRASTIM EXCL BIOSIMIL", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1442", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.96, "maximum": 2.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FOSNETUPITANT, PALONOSET", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1454", "type": "HCPCS"}], "standard_charges": [{"minimum": 674.57, "maximum": 1541.88, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1541.88, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 674.57, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ GEMCITABINE HCL (ACCORD)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9196", "type": "HCPCS"}], "standard_charges": [{"minimum": 8.53, "maximum": 19.49, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 19.49, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 8.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ GIVOSIRAN 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0223", "type": "HCPCS"}], "standard_charges": [{"minimum": 108.92, "maximum": 248.95, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 248.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 108.92, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ GLOFITAMAB GXBM, 2.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9286", "type": "HCPCS"}], "standard_charges": [{"minimum": 2631.44, "maximum": 6014.71, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6014.71, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2631.44, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ GLUCAGON HCL, FRESENIUS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1611", "type": "HCPCS"}], "standard_charges": [{"minimum": 120.33, "maximum": 275.04, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 275.04, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 120.33, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HEPARIN, PFIZER, 1000U", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1643", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.45, "maximum": 10.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 10.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4.45, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HERZUMA 10 MG", "code_information": [{"code": "Q5113", "type": "HCPCS"}], "standard_charges": [{"minimum": 39.17, "maximum": 89.52, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 89.52, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 39.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HUMAN FIBRINOGEN CON NOS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7178", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.34, "maximum": 3.07, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.07, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HYDROXYPROGST CAPOAT NOS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1729", "type": "HCPCS"}], "standard_charges": [{"minimum": 17.67, "maximum": 40.39, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 40.39, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.67, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ IMIP 4 CILAS 4 RELEB 2MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0742", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.39, "maximum": 5.47, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5.47, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ INOTUZUMAB OZOGAM 0.1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9229", "type": "HCPCS"}], "standard_charges": [{"minimum": 2507.26, "maximum": 5730.89, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5730.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2507.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ IRINOTECAN LIPOSOME 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9205", "type": "HCPCS"}], "standard_charges": [{"minimum": 60.27, "maximum": 137.76, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 137.76, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 60.27, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ IRON DEXTRAN", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1750", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.83, "maximum": 38.47, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 38.47, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 16.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ IVIG PRIVIGEN 500 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1459", "type": "HCPCS"}], "standard_charges": [{"minimum": 46.92, "maximum": 107.26, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 107.26, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 46.92, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LABETALOL HCL HIKMA, 5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1921", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.49, "maximum": 5.69, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5.69, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.49, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LEFAMULIN 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0691", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.7, "maximum": 1.61, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.7, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LEVOLEUCOVORIN NOS 0.5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0641", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.06, "maximum": 0.14, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 0.14, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LON TESIRIN-LPYL 0.075MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9359", "type": "HCPCS"}], "standard_charges": [{"minimum": 194.96, "maximum": 445.63, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 445.63, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 194.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LUSPATERCEPT-AAMT 0.25MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0896", "type": "HCPCS"}], "standard_charges": [{"minimum": 38.84, "maximum": 88.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 88.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 38.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LUXTURNA 1 BILLION VEC G", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3398", "type": "HCPCS"}], "standard_charges": [{"minimum": 2791.15, "maximum": 6379.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6379.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2791.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MELPHA HYDROCH NOS 50 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9245", "type": "HCPCS"}], "standard_charges": [{"minimum": 143.84, "maximum": 328.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 328.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 143.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MIDAZOLAM (WG CRIT CARE)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2251", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.27, "maximum": 0.62, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 0.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.27, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MOGAMULIZUMAB-KPKC, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9204", "type": "HCPCS"}], "standard_charges": [{"minimum": 227.56, "maximum": 520.13, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 520.13, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 227.56, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MOSUNETUZUMAB-AXGB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9350", "type": "HCPCS"}], "standard_charges": [{"minimum": 611.85, "maximum": 1398.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1398.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 611.85, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MOXIFLOXACIN (FRES KABI)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2281", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.64, "maximum": 12.89, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MVASI 10 MG", "code_information": [{"code": "Q5107", "type": "HCPCS"}], "standard_charges": [{"minimum": 24.9, "maximum": 56.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 56.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 24.9, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ NIVOL RELATLIMAB 3MG/1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9298", "type": "HCPCS"}], "standard_charges": [{"minimum": 181.87, "maximum": 415.7, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 415.7, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 181.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ OGIVRI 10 MG", "code_information": [{"code": "Q5114", "type": "HCPCS"}], "standard_charges": [{"minimum": 43.18, "maximum": 98.69, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 98.69, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 43.18, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ OLIPUDASE ALFA-RPCP 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0218", "type": "HCPCS"}], "standard_charges": [{"minimum": 366.31, "maximum": 837.29, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 837.29, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 366.31, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ONASE ABEPAR-XIOI TREAT", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3399", "type": "HCPCS"}], "standard_charges": [{"minimum": 2237740.22, "maximum": 5114834.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5114834.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2237740.22, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ONTRUZANT 10 MG", "code_information": [{"code": "Q5112", "type": "HCPCS"}], "standard_charges": [{"minimum": 37.83, "maximum": 86.47, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 86.47, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 37.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEGFILGRAST EX BIO 0.5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2506", "type": "HCPCS"}], "standard_charges": [{"minimum": 49.25, "maximum": 112.56, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 112.56, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 49.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEGFILGRASTIM-BMEZ 0.5MG", "code_information": [{"code": "Q5120", "type": "HCPCS"}], "standard_charges": [{"minimum": 336.96, "maximum": 770.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 770.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 336.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMBROLIZUMAB", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9271", "type": "HCPCS"}], "standard_charges": [{"minimum": 54.16, "maximum": 123.79, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 123.79, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 54.16, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMETREXED (ACCORD) 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9296", "type": "HCPCS"}], "standard_charges": [{"minimum": 9.39, "maximum": 21.46, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 21.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMETREXED (SANDOZ) 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9297", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.26, "maximum": 2.88, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.88, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMETREXED (TEVA) 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9314", "type": "HCPCS"}], "standard_charges": [{"minimum": 19.39, "maximum": 44.33, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 44.33, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 19.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMETREXED DITROMETHAMIN", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9323", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.84, "maximum": 13.34, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 13.34, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMETREXED, HOSPIRA 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9294", "type": "HCPCS"}], "standard_charges": [{"minimum": 10.26, "maximum": 23.45, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 23.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 10.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PLASMINOGEN TVMH 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2998", "type": "HCPCS"}], "standard_charges": [{"minimum": 30.9, "maximum": 70.63, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 70.63, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 30.9, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RECOMBIN ESPEROCT PER IU", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7204", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.02, "maximum": 4.61, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RETACRIT ESRD ON DIALYSI", "code_information": [{"code": "Q5105", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.76, "maximum": 1.73, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.73, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.76, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RETACRIT NON-ESRD USE", "code_information": [{"code": "Q5106", "type": "HCPCS"}], "standard_charges": [{"minimum": 7.6, "maximum": 17.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 17.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 7.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RISANKIZUMAB-RZAA 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2327", "type": "HCPCS"}], "standard_charges": [{"minimum": 14.93, "maximum": 34.13, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 34.13, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 14.93, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RISPERDAL CONSTA, 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2794", "type": "HCPCS"}], "standard_charges": [{"minimum": 11.81, "maximum": 27.0, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 27.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 11.81, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RITUXIMAB, HYALURONIDASE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9311", "type": "HCPCS"}], "standard_charges": [{"minimum": 36.35, "maximum": 83.09, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 83.09, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 36.35, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ROCTAVIAN ML 2X10^13VC G", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1412", "type": "HCPCS"}], "standard_charges": [{"minimum": 11668.64, "maximum": 26671.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 26671.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 11668.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ROMIDEPSIN LYOPHIL 0.1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9319", "type": "HCPCS"}], "standard_charges": [{"minimum": 31.06, "maximum": 70.99, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 70.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 31.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ROMIDEPSIN NON-LYO 0.1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9318", "type": "HCPCS"}], "standard_charges": [{"minimum": 32.95, "maximum": 75.31, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 75.31, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 32.95, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RONZANOLIXIZUM-NOLI 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9333", "type": "HCPCS"}], "standard_charges": [{"minimum": 21.63, "maximum": 49.44, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 49.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 21.63, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RUXIENCE, 10 MG", "code_information": [{"code": "Q5119", "type": "HCPCS"}], "standard_charges": [{"minimum": 19.87, "maximum": 45.41, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 45.41, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 19.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ SEBELIPASE ALFA 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2840", "type": "HCPCS"}], "standard_charges": [{"minimum": 523.53, "maximum": 1196.64, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1196.64, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 523.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ SECRETIN SYNTHETIC HUMAN", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2850", "type": "HCPCS"}], "standard_charges": [{"minimum": 40.56, "maximum": 92.71, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 92.71, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 40.56, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ SIROLIMUS PROT PART 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9331", "type": "HCPCS"}], "standard_charges": [{"minimum": 106.2, "maximum": 242.74, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 242.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 106.2, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ SODIUM THIOSULFATE 100MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0208", "type": "HCPCS"}], "standard_charges": [{"minimum": 93.47, "maximum": 213.65, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 213.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 93.47, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TALIMOGENE LAHERPAREPVEC", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9325", "type": "HCPCS"}], "standard_charges": [{"minimum": 64.7, "maximum": 147.89, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 147.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 64.7, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TALQUETAMAB-TGVS 0.25 MG", "code_information": [{"code": "C9163", "type": "HCPCS"}], "standard_charges": [{"minimum": 64.81, "maximum": 148.13, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 148.13, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 64.81, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TBO FILGRASTIM 1 MICROG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1447", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.43, "maximum": 0.98, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 0.98, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.43, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TECLISTAMAB CQYV 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9380", "type": "HCPCS"}], "standard_charges": [{"minimum": 29.98, "maximum": 68.52, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 68.52, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 29.98, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TEDIZOLID PHOSPHATE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3090", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.73, "maximum": 3.96, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.96, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.73, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TEPLIZUMAB MZWV 5 MCG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9381", "type": "HCPCS"}], "standard_charges": [{"minimum": 35.23, "maximum": 80.52, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 80.52, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 35.23, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TEZEPELUMAB-EKKO, 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2356", "type": "HCPCS"}], "standard_charges": [{"minimum": 18.06, "maximum": 41.28, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 41.28, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 18.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TISOTU VEDOTIN-TFTV, 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9273", "type": "HCPCS"}], "standard_charges": [{"minimum": 163.56, "maximum": 373.85, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 373.85, "methodology": "fee 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79.73, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 79.73, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 34.88, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ UBLITUXIMAB-XIIY, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2329", "type": "HCPCS"}], "standard_charges": [{"minimum": 65.75, "maximum": 150.29, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 150.29, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 65.75, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ VASOPRESSIN (AM REG) 1 U", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2599", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.45, "maximum": 1.03, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.03, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.45, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ VELMANASE ALFA-TYCV 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0217", "type": "HCPCS"}], "standard_charges": [{"minimum": 412.02, "maximum": 941.76, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 941.76, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 412.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ W/FLUOR EVAL CV DEVICE", "code_information": [{"code": "36598", "type": "CPT"}], "standard_charges": [{"minimum": 79.46, "maximum": 453.6, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 88.2, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 453.6, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 79.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 198.45, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 79.84, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 83.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 178.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ XIPERE 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3299", "type": "HCPCS"}], "standard_charges": [{"minimum": 47.21, "maximum": 107.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 107.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 47.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ABILIFY ASIMTUFII, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0402", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.72, "maximum": 13.08, "setting": "outpatient", "payers_information": 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"drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0172", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.81, "maximum": 13.27, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 13.27, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.81, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, AFLIBERCEPT HD, 1 MG", "code_information": [{"code": "C9161", "type": "HCPCS"}], "standard_charges": [{"minimum": 328.42, "maximum": 750.67, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 750.67, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 328.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, AFSTYLA, 1 I.U.", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7210", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.41, "maximum": 3.22, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.41, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, AMISULPRIDE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0184", "type": "HCPCS"}], "standard_charges": [{"minimum": 8.82, "maximum": 20.16, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 20.16, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 8.82, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, AMIVANTAMAB-VMJW", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9061", "type": "HCPCS"}], "standard_charges": [{"minimum": 19.41, "maximum": 44.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 44.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 19.41, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, APONVIE, 1 MG", "code_information": [{"code": "C9145", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.83, "maximum": 4.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4.18, "methodology": "fee schedule"}, {"payer_name": 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"plan_name": "Commercial", "standard_charge_dollar": 113.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 49.52, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ATEZOLIZUMAB,10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9022", "type": "HCPCS"}], "standard_charges": [{"minimum": 82.61, "maximum": 188.83, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 188.83, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 82.61, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, AVACINCAPTAD PEG 0.1 MG", "code_information": [{"code": "C9162", "type": "HCPCS"}], "standard_charges": [{"minimum": 105.09, "maximum": 240.22, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 240.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 105.09, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BALFAXAR, PER I.U", "code_information": [{"code": "C9159", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.15, "maximum": 7.2, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7.2, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BENDAMUSTINE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9056", "type": "HCPCS"}], "standard_charges": 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{"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2372", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.17, "maximum": 0.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 0.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BORTEZOMIB FRESENIUSKAB", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9048", "type": "HCPCS"}], "standard_charges": [{"minimum": 47.18, "maximum": 107.83, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 107.83, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 47.18, "methodology": "fee 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REDDY'S", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9046", "type": "HCPCS"}], "standard_charges": [{"minimum": 47.18, "maximum": 107.83, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 107.83, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 47.18, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BORTEZOMIB, HOSPIRA", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9049", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.48, "maximum": 3.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.48, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BROLUCIZUMAB-DBLL, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0179", "type": "HCPCS"}], "standard_charges": [{"minimum": 316.05, "maximum": 722.4, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 722.4, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 316.05, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BUPIVACAINE (POSIMIR)", "code_information": [{"code": "C9144", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.49, "maximum": 1.13, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.13, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.49, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BUPIVACAINE, NOS, 0.5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0665", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.01, "maximum": 0.02, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 0.02, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.01, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CABOTE RILPIVIR 2MG 3MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0741", "type": "HCPCS"}], "standard_charges": [{"minimum": 21.96, "maximum": 50.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 50.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 21.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CARMUSTINE (ACCORD)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9052", "type": "HCPCS"}], "standard_charges": [{"minimum": 17.88, "maximum": 40.87, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 40.87, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.88, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CEFEPIME HCL (B BRAUN)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0703", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.12, "maximum": 11.71, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 11.71, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.12, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CEFIDEROCOL, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0699", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.11, "maximum": 4.82, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4.82, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.11, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CIMERLI, 0.1 MG", "code_information": [{"code": "Q5128", "type": "HCPCS"}], 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{"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 226.67, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, DUROLANE 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7318", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.97, "maximum": 13.66, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 13.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ELAHERE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9063", "type": "HCPCS"}], "standard_charges": [{"minimum": 63.85, "maximum": 145.94, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 145.94, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 63.85, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ELRANATAMAB-BCMM, 1 MG", "code_information": [{"code": "C9165", "type": "HCPCS"}], "standard_charges": [{"minimum": 171.87, "maximum": 392.86, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 392.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 171.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, EPINEPHRINE (BELCHER)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0173", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.74, "maximum": 3.98, "setting": 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"J0606", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.54, "maximum": 5.81, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.54, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, EVINACUMAB-DGNB, 5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1305", "type": "HCPCS"}], "standard_charges": [{"minimum": 174.08, "maximum": 397.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 397.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 174.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, FACTOR X, (HUMAN), 1IU", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7175", "type": "HCPCS"}], "standard_charges": [{"minimum": 8.85, "maximum": 20.23, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 20.23, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 8.85, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, FARICIMAB-SVOA, 0.1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2777", "type": "HCPCS"}], "standard_charges": [{"minimum": 35.07, "maximum": 80.16, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 80.16, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", 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"maximum": 8240473.92, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8240473.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3605207.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, IMM GLOB BIVIGAM, 500MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1556", "type": "HCPCS"}], "standard_charges": [{"minimum": 70.9, "maximum": 162.05, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 162.05, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70.9, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, INVEGA HAFYERA/TRINZA", "drug_information": 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First", "plan_name": "Commercial", "standard_charge_dollar": 2.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, NUSINERSEN, 0.1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2326", "type": "HCPCS"}], "standard_charges": [{"minimum": 1138.78, "maximum": 2602.92, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2602.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1138.78, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, NYVEPRIA", "code_information": [{"code": "Q5122", "type": "HCPCS"}], "standard_charges": [{"minimum": 60.62, "maximum": 138.55, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 138.55, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 60.62, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, OLICERIDINE 0.1 MG", "code_information": [{"code": "C9101", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.16, "maximum": 2.64, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.64, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.16, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, OMACETAXINE MEP, 0.01MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9262", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.84, "maximum": 8.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, PANZYGA, 500 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1576", "type": "HCPCS"}], "standard_charges": [{"minimum": 64.56, "maximum": 147.58, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 147.58, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 64.56, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, PASIREOTIDE LONG ACTING", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2502", "type": "HCPCS"}], "standard_charges": [{"minimum": 436.8, "maximum": 998.4, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 998.4, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 436.8, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, PEGCETACOPLAN, 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2781", "type": "HCPCS"}], "standard_charges": [{"minimum": 147.19, "maximum": 336.43, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 336.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 147.19, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, POLATUZUMAB VEDOTIN 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9309", "type": "HCPCS"}], "standard_charges": [{"minimum": 120.78, "maximum": 276.07, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 276.07, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 120.78, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, RELEUKO 1 MCG", "code_information": [{"code": "Q5125", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.53, "maximum": 1.2, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.2, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, REMDESIVIR, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0248", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.89, "maximum": 13.46, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 13.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.89, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, RETIFANLIMAB-DLWR, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9345", "type": "HCPCS"}], "standard_charges": [{"minimum": 28.99, "maximum": 66.26, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 66.26, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 28.99, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, REZAFUNGIN, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0349", "type": "HCPCS"}], "standard_charges": [{"minimum": 9.75, "maximum": 22.3, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 22.3, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9.75, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, RIMABOTULINUMTOXINB", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0587", "type": "HCPCS"}], "standard_charges": [{"minimum": 12.66, "maximum": 28.94, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 28.94, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 12.66, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, SCULPTRA, 0.5MG", "code_information": [{"code": "Q2028", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.37, "maximum": 3.12, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.12, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.37, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, SPESOLIMAB-SBZO, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1747", "type": "HCPCS"}], "standard_charges": [{"minimum": 58.53, "maximum": 133.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 133.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 58.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, STIMUFEND, 0.5 MG", "code_information": [{"code": "Q5127", "type": "HCPCS"}], "standard_charges": [{"minimum": 319.36, "maximum": 729.96, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 729.96, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 319.36, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, SUSVIMO 0.1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2779", "type": "HCPCS"}], "standard_charges": [{"minimum": 78.5, "maximum": 179.42, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 179.42, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 78.5, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, SUTIMLIMAB-JOME, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1302", "type": "HCPCS"}], "standard_charges": [{"minimum": 17.26, "maximum": 39.46, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 39.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, TALIGLUCERASE ALFA 10 U", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3060", "type": "HCPCS"}], "standard_charges": [{"minimum": 43.76, "maximum": 100.03, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 100.03, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 43.76, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, TEBENTAFUSP-TEBN, 1 MCG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9274", "type": "HCPCS"}], "standard_charges": [{"minimum": 203.03, "maximum": 464.06, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 464.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 203.03, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, TREMELIMUMAB-ACTL, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9347", "type": "HCPCS"}], "standard_charges": [{"minimum": 132.25, "maximum": 302.28, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 302.28, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 132.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, TRIVISC 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7329", "type": "HCPCS"}], "standard_charges": [{"minimum": 7.69, "maximum": 17.57, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 17.57, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 7.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, UZEDY, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2799", "type": "HCPCS"}], "standard_charges": [{"minimum": 24.0, "maximum": 54.86, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 54.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 24.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VANCOMYCIN HCL (MYLAN)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3371", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.81, "maximum": 13.27, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 13.27, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.81, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VANCOMYCIN HCL (XELLIA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3372", "type": "HCPCS"}], "standard_charges": [{"minimum": 6.39, "maximum": 14.62, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 14.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 6.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VASOPRESSIN, 1 UNIT", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2598", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.76, "maximum": 4.03, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4.03, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.76, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VEGZELMA, 10 MG", "code_information": [{"code": "Q5129", "type": "HCPCS"}], "standard_charges": [{"minimum": 70.37, "maximum": 160.85, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 160.85, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70.37, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VINCRISTINE SUL LIP 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9371", "type": "HCPCS"}], "standard_charges": [{"minimum": 3324.15, "maximum": 7598.06, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7598.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3324.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VUTRISIRAN, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0225", "type": "HCPCS"}], "standard_charges": [{"minimum": 4807.64, "maximum": 10988.88, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 10988.88, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4807.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ZIV-AFLIBERCEPT, 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9400", "type": "HCPCS"}], "standard_charges": [{"minimum": 7.08, "maximum": 16.18, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 16.18, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 7.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. (ANI), UP TO 40 UNITS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0802", "type": "HCPCS"}], "standard_charges": [{"minimum": 3254.39, "maximum": 7438.61, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7438.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3254.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. ACTHAR GEL TO 40 UNITS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0801", "type": "HCPCS"}], "standard_charges": [{"minimum": 3979.64, "maximum": 9096.31, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 9096.31, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3979.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. ASCENIV", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1554", "type": "HCPCS"}], "standard_charges": [{"minimum": 477.53, "maximum": 1091.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1091.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 477.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. AVSOLA, 10 MG", "code_information": [{"code": "Q5121", "type": "HCPCS"}], "standard_charges": [{"minimum": 24.83, "maximum": 56.76, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 56.76, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 24.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. BELRAPZO/BENDAMUSTINE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9036", "type": "HCPCS"}], "standard_charges": [{"minimum": 12.72, "maximum": 29.06, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 29.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 12.72, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. BYOOVIZ, 0.1 MG", "code_information": [{"code": "Q5124", "type": "HCPCS"}], "standard_charges": [{"minimum": 182.22, "maximum": 416.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 416.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 182.22, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. CEFEPIME HCL (BAXTER)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0701", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.48, "maximum": 12.53, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5.48, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. CETIRIZINE HCL 0.5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1201", "type": "HCPCS"}], "standard_charges": [{"minimum": 14.65, "maximum": 33.48, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 33.48, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 14.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. EPTINEZUMAB-JJMR 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3032", "type": "HCPCS"}], "standard_charges": [{"minimum": 17.55, "maximum": 40.1, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 40.1, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 17.55, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. FE DERISOMALTOSE 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1437", "type": "HCPCS"}], "standard_charges": [{"minimum": 18.33, "maximum": 41.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 41.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 18.33, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. HERCEPTIN HYLECTA, 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9356", "type": "HCPCS"}], "standard_charges": [{"minimum": 64.16, "maximum": 146.64, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 146.64, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 64.16, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. INEBILIZUMAB-CDON, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1823", "type": "HCPCS"}], "standard_charges": [{"minimum": 460.14, "maximum": 1051.75, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1051.75, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 460.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. INFUGEM, 100 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9198", "type": "HCPCS"}], "standard_charges": [{"minimum": 39.14, "maximum": 89.47, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 89.47, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 39.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. ISATUXIMAB-IRFC 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9227", "type": "HCPCS"}], "standard_charges": [{"minimum": 74.34, "maximum": 169.92, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 169.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 74.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. JIVI 1 IU", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7208", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.28, "maximum": 5.21, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5.21, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. LUMASIRAN, 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0224", "type": "HCPCS"}], "standard_charges": [{"minimum": 310.53, "maximum": 709.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 709.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 310.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. LURBINECTEDIN, 0.1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9223", "type": "HCPCS"}], "standard_charges": [{"minimum": 194.36, "maximum": 444.24, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 444.24, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 194.36, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. MARGETUXIMAB-CMKB, 5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9353", "type": "HCPCS"}], "standard_charges": [{"minimum": 45.72, "maximum": 104.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 104.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 45.72, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. MYCOPHENOLATE MOFETIL", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7519", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.7, "maximum": 1.61, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.7, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. NAXITAMAB-GQGK, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9348", "type": "HCPCS"}], "standard_charges": [{"minimum": 592.55, "maximum": 1354.39, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1354.39, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 592.55, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. OLANZAPINE, 0.5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2359", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.92, "maximum": 2.11, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.11, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 0.92, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. PEMETREXED NOS 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9305", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.25, "maximum": 9.72, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 9.72, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. PEMETREXED, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9304", "type": "HCPCS"}], "standard_charges": [{"minimum": 60.55, "maximum": 138.41, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 138.41, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 60.55, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. RIABNI, 10 MG", "code_information": [{"code": "Q5123", "type": "HCPCS"}], "standard_charges": [{"minimum": 40.25, "maximum": 91.99, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 91.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 40.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. ROMOSOZUMAB-AQQG 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3111", "type": "HCPCS"}], "standard_charges": [{"minimum": 10.43, "maximum": 23.83, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 23.83, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 10.43, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. TAGRAXOFUSP-ERZS 10 MCG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9269", "type": "HCPCS"}], "standard_charges": [{"minimum": 316.35, "maximum": 723.1, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 723.1, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 316.35, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. TEPROTUMUMAB-TRBW 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3241", "type": "HCPCS"}], "standard_charges": [{"minimum": 318.74, "maximum": 728.54, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 728.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 318.74, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. TIGECYCLINE (ACCORD)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3244", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.58, "maximum": 5.9, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.58, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. VILTOLARSEN", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1427", "type": "HCPCS"}], "standard_charges": [{"minimum": 57.17, "maximum": 130.68, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 130.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 57.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. XEMBIFY, 100 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1558", "type": "HCPCS"}], "standard_charges": [{"minimum": 13.79, "maximum": 31.51, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 31.51, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 13.79, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., APREPITANT, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0185", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.68, "maximum": 3.84, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3.84, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., ARISTADA INITIO, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1943", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.0, "maximum": 6.86, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., BENDEKA 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9034", "type": "HCPCS"}], "standard_charges": [{"minimum": 14.34, "maximum": 32.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 32.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 14.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., BENRALIZUMAB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0517", "type": "HCPCS"}], "standard_charges": [{"minimum": 164.71, "maximum": 376.49, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 376.49, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 164.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., BREXANOLONE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1632", "type": "HCPCS"}], "standard_charges": [{"minimum": 70.07, "maximum": 160.15, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 160.15, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70.07, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., CEMIPLIMAB-RWLC, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9119", "type": "HCPCS"}], "standard_charges": [{"minimum": 26.68, "maximum": 60.98, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 60.98, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 26.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., COPANLISIB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9057", "type": "HCPCS"}], "standard_charges": [{"minimum": 85.09, "maximum": 194.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 194.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 85.09, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., DURVALUMAB, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9173", "type": "HCPCS"}], "standard_charges": [{"minimum": 78.42, "maximum": 179.26, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 179.26, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 78.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., EMAPALUMAB-LZSG, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9210", "type": "HCPCS"}], "standard_charges": [{"minimum": 365.04, "maximum": 834.38, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 834.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 365.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., EMICIZUMAB-KXWH 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7170", "type": "HCPCS"}], "standard_charges": [{"minimum": 49.22, "maximum": 112.51, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 112.51, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 49.22, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., ERAVACYCLINE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0122", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.09, "maximum": 2.5, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.09, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., EVOMELA, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9246", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.02, "maximum": 36.62, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 36.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 16.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., FIBRYGA, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7177", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.07, "maximum": 2.45, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 2.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.07, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., FREMANEZUMAB-VFRM 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3031", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.79, "maximum": 4.08, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4.08, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1.79, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., GUSELKUMAB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1628", "type": "HCPCS"}], "standard_charges": [{"minimum": 70.46, "maximum": 161.04, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 161.04, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70.46, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., IBALIZUMAB-UIYK, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1746", "type": "HCPCS"}], "standard_charges": [{"minimum": 72.51, "maximum": 165.74, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 165.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 72.51, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., ILUVIEN, 0.01 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7313", "type": "HCPCS"}], "standard_charges": [{"minimum": 477.08, "maximum": 1090.46, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1090.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 477.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., KANJINTI, 10 MG", "code_information": [{"code": "Q5117", "type": "HCPCS"}], "standard_charges": [{"minimum": 13.07, "maximum": 29.88, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 29.88, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 13.07, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., LUMOXITI, 0.01 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9313", "type": "HCPCS"}], "standard_charges": [{"minimum": 22.73, "maximum": 51.96, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 51.96, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 22.73, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., MEROPENEM, VABORBACTAM", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2186", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.02, "maximum": 4.61, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., OMADACYCLINE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0121", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.56, "maximum": 8.14, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 8.14, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.56, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., PATISIRAN, 0.1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0222", "type": "HCPCS"}], "standard_charges": [{"minimum": 97.16, "maximum": 222.07, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 222.07, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 97.16, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., PERSERIS, 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2798", "type": "HCPCS"}], "standard_charges": [{"minimum": 11.3, "maximum": 25.82, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 25.82, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 11.3, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., PLAZOMICIN, 5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0291", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.5, "maximum": 7.99, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3.5, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., RAVULIZUMAB-CWVZ 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1303", "type": "HCPCS"}], "standard_charges": [{"minimum": 215.51, "maximum": 492.6, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 492.6, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 215.51, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., RETISERT, 0.01 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7311", "type": "HCPCS"}], "standard_charges": [{"minimum": 290.6, "maximum": 664.22, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 664.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 290.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., RITUXIMAB, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9312", "type": "HCPCS"}], "standard_charges": [{"minimum": 76.97, "maximum": 175.92, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 175.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 76.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., TAFASITAMAB-CXIX", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9349", "type": "HCPCS"}], "standard_charges": [{"minimum": 13.21, "maximum": 30.19, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 30.19, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 13.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., TILDRAKIZUMAB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3245", "type": "HCPCS"}], "standard_charges": [{"minimum": 136.68, "maximum": 312.41, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 312.41, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 136.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., TRAZIMERA, 10 MG", "code_information": [{"code": "Q5116", "type": "HCPCS"}], "standard_charges": [{"minimum": 15.91, "maximum": 36.36, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 36.36, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 15.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., TREANDA 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9033", "type": "HCPCS"}], "standard_charges": [{"minimum": 8.94, "maximum": 20.42, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 20.42, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 8.94, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., TRILURON, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7332", "type": "HCPCS"}], "standard_charges": [{"minimum": 9.98, "maximum": 22.8, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 22.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 9.98, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., TRIPTORELIN XR 3.75 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3316", "type": "HCPCS"}], "standard_charges": [{"minimum": 3136.19, "maximum": 7168.44, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7168.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3136.19, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., YUTIQ, 0.01 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7314", "type": "HCPCS"}], "standard_charges": [{"minimum": 514.06, "maximum": 1174.99, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1174.99, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 514.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., ZIRABEV, 10 MG", "code_information": [{"code": "Q5118", "type": "HCPCS"}], "standard_charges": [{"minimum": 20.91, "maximum": 47.78, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 47.78, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 20.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECT SKIN LESIONS >7", "code_information": [{"code": "11901", "type": "CPT"}], "standard_charges": [{"minimum": 150.27, "maximum": 423.7, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 165.99, "methodology": "fee 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"standard_charge_dollar": 37.03, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 616.51, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 34.88, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 269.72, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 33.52, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 35.08, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 74.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECT/TREAT EYE SOCKET", "code_information": [{"code": "67515", "type": 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"standard_charge_dollar": 69.29, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION EYE DRUG", "code_information": [{"code": "67028", "type": "CPT"}], "standard_charges": [{"minimum": 40.66, "maximum": 716.71, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 44.92, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 716.71, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 48.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 313.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 40.66, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 42.55, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 90.78, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION GLATIRAMER ACETATE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1595", "type": "HCPCS"}], "standard_charges": [{"minimum": 151.57, "maximum": 346.44, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 346.44, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 151.57, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION INTO BRAIN CANAL", "code_information": [{"code": "61026", "type": "CPT"}], "standard_charges": [{"minimum": 262.86, "maximum": 1463.52, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 593.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1463.52, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 262.86, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 640.29, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 537.54, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 562.55, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1200.1, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION INTO BRAIN CANAL", "code_information": [{"code": "61055", "type": "CPT"}], "standard_charges": [{"minimum": 108.15, "maximum": 626.81, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 248.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 108.15, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 274.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 225.12, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 235.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 502.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION INTO HEMORRHOID(S)", "code_information": [{"code": "46500", "type": "CPT"}], "standard_charges": [{"minimum": 202.68, "maximum": 1934.21, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 223.89, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1934.21, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 210.13, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 846.22, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 202.68, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 212.1, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 452.49, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION INTO SPINAL ARTERY", "code_information": [{"code": "62294", "type": "CPT"}], "standard_charges": [{"minimum": 698.36, "maximum": 1928.95, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 771.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1928.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 843.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 698.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 730.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1559.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION INTO VOCAL CORD", "code_information": [{"code": "31513", "type": "CPT"}], "standard_charges": [{"minimum": 155.59, "maximum": 864.14, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 359.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 864.14, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 155.59, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 378.06, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 324.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 340.1, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 725.55, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION INTRAOP ADD-ON", "code_information": [{"code": "48400", "type": "CPT"}], "standard_charges": [{"minimum": 95.15, "maximum": 212.43, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 105.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 95.15, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 99.58, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 212.43, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION OF HIV PREP DRUG", "code_information": [{"code": "G0012", "type": "HCPCS"}], "standard_charges": [{"minimum": 43.98, "maximum": 100.54, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 100.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 43.98, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION OF SINUS TRACT; THERAPEUTIC (SEPARATE PROCEDURE)", "code_information": [{"code": "20500", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 57.1, "maximum": 3227.45, "gross_charge": 4389.0, "discounted_cash": 2633.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 63.08, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3227.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 60.63, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1412.01, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 57.1, "methodology": "fee 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ARTHROGRAPHY AND/OR ANESTHETIC/STEROID", "code_information": [{"code": "27096", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 73.76, "maximum": 164.68, "gross_charge": 1316.0, "discounted_cash": 789.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 81.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 73.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 77.19, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 164.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT AND ARTHROGRAPHY", "code_information": [{"code": "G0260", "type": "HCPCS"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 537.54, "maximum": 1463.52, "gross_charge": 4535.0, "discounted_cash": 2721.0, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 593.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1463.52, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 640.29, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 537.54, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 562.55, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": 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"methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4931.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 849.94, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2157.63, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1738.8, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1819.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3881.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION TREATMENT OF EYE", "code_information": [{"code": "66030", "type": "CPT"}], "standard_charges": 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3881.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION TREATMENT OF NERVE", "code_information": [{"code": "64600", "type": "CPT"}], "standard_charges": [{"minimum": 340.77, "maximum": 1928.95, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 771.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1928.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 340.77, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 843.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 698.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 730.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1559.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION TREATMENT OF NERVE", "code_information": [{"code": "64610", "type": "CPT"}], "standard_charges": [{"minimum": 659.94, "maximum": 4086.1, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1633.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4086.1, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 659.94, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1787.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1478.64, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1547.42, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3301.15, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION TREATMENT OF NERVE", "code_information": [{"code": "64681", "type": "CPT"}], "standard_charges": [{"minimum": 340.77, "maximum": 1928.95, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 771.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1928.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 340.77, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 843.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 698.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 730.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1559.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION TREATMENT OF NOSE", "code_information": [{"code": "30200", "type": "CPT"}], "standard_charges": [{"minimum": 67.27, "maximum": 1164.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 78.52, "methodology": 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WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL", "code_information": [{"code": "64490", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 340.77, "maximum": 1928.95, "gross_charge": 6584.0, "discounted_cash": 3950.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 771.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1928.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 340.77, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 843.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 698.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 730.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1559.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL", "code_information": [{"code": "64493", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 340.77, "maximum": 1928.95, "gross_charge": 6584.0, "discounted_cash": 3950.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 771.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1928.95, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 340.77, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 843.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 698.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 730.85, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1559.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED", "code_information": [{"code": "232T", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 312.69, "maximum": 843.22, "gross_charge": 1888.0, "discounted_cash": 1132.8, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 345.41, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 843.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 368.91, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 312.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 327.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 698.09, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO MUSCLE(S)", "code_information": [{"code": "20552", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 23.26, "maximum": 626.81, "gross_charge": 1463.0, "discounted_cash": 877.8, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 28.8, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 23.26, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 274.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 26.08, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 27.29, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 58.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE MUSCLE(S)", "code_information": [{"code": "20553", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 27.13, "maximum": 626.81, "gross_charge": 1463.0, "discounted_cash": 877.8, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 33.6, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 27.13, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 274.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 30.42, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 31.83, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 67.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR FASCIA)", "code_information": [{"code": "20550", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 22.34, "maximum": 626.81, "gross_charge": 3585.0, "discounted_cash": 2151.0, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 24.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 23.54, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 274.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 22.34, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 23.38, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 49.88, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION(S); TENDON ORIGIN/INSERTION", "code_information": [{"code": "20551", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 23.59, "maximum": 626.81, "gross_charge": 3585.0, "discounted_cash": 2151.0, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 26.06, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 24.36, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 274.23, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 23.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 24.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 52.67, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION, ALEMTUZUMAB", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0202", "type": "HCPCS"}], "standard_charges": [{"minimum": 2258.69, "maximum": 5162.71, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5162.71, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2258.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)", "code_information": [{"code": "64472", "type": 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(INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OT", "code_information": [{"code": "62311", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 4535.0, "discounted_cash": 2721.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL", "code_information": [{"code": "20526", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 35.69, "maximum": 626.81, "gross_charge": 1463.0, "discounted_cash": 877.8, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 39.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 626.81, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 36.54, "methodology": "fee schedule"}, 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"plan_name": "Advantage", "standard_charge_dollar": 8816.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 9226.75, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 19683.72, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT HEART PM VENTRICULAR", "code_information": [{"code": "33207", "type": "CPT"}], "standard_charges": [{"minimum": 6323.37, "maximum": 19683.72, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 9739.34, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7957.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 6323.37, "methodology": "fee 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"methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 4605.24, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 3673.52, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 3844.39, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 8201.36, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT I-AORT PERCUT DEVICE", "code_information": [{"code": "33967", "type": "CPT"}], "standard_charges": [{"minimum": 234.32, "maximum": 523.12, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 258.84, "methodology": "fee schedule"}, {"payer_name": "blue cross 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"standard_charge_dollar": 1838.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3921.29, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT LEVONORGESTREL IUS", "code_information": [{"code": "S4981", "type": "HCPCS"}], "standard_charges": [{"minimum": 929.69, "maximum": 2075.6, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1026.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 929.69, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 972.94, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 2075.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT MAJOR VESSEL GRAFT", "code_information": [{"code": "33330", "type": "CPT"}], "standard_charges": [{"minimum": 1281.28, "maximum": 2860.53, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1415.37, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1281.28, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1340.87, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 2860.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT MAJOR VESSEL GRAFT", "code_information": [{"code": "33335", "type": "CPT"}], "standard_charges": [{"minimum": 1692.57, 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"fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 42689.42, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 18676.62, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 15113.61, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 15816.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 33742.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT NEEDLE BONE CAVITY", "code_information": [{"code": "36680", "type": "CPT"}], "standard_charges": [{"minimum": 312.69, "maximum": 843.22, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of 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"plan_name": "Commercial", "standard_charge_dollar": 6745.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1118.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2951.22, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1402.77, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1468.02, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3131.77, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT OCULAR IMPLANT", "code_information": [{"code": "65130", "type": "CPT"}], "standard_charges": [{"minimum": 1103.42, "maximum": 8182.42, "setting": "outpatient", 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"standard_charge_dollar": 1118.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2951.22, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2383.3, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2494.15, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5320.86, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT PLEURAL CATH", "code_information": [{"code": "32550", "type": "CPT"}], "standard_charges": [{"minimum": 1551.5, "maximum": 7321.68, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2953.87, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7321.68, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1551.5, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3203.24, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2674.03, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2798.41, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5969.93, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT PROST URETHRAL STENT", "code_information": [{"code": "53855", "type": "CPT"}], "standard_charges": [{"minimum": 511.34, 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"135.3", "type": "APR-DRG"}], "standard_charges": [{"minimum": 5515.23, "maximum": 5515.23, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 5515.23, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Chest And Respiratory Trauma, Minor", "code_information": [{"code": "135.1", "type": "APR-DRG"}], "standard_charges": [{"minimum": 3481.87, "maximum": 3481.87, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 3481.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Chest And Respiratory Trauma, Moderate", "code_information": [{"code": "135.2", "type": "APR-DRG"}], "standard_charges": [{"minimum": 4612.25, "maximum": 4612.25, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", 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Except Sickle Cell Crisis And Coagulation, Major", "code_information": [{"code": "660.3", "type": "APR-DRG"}], "standard_charges": [{"minimum": 7784.44, "maximum": 7784.44, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 7784.44, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation, Minor", "code_information": [{"code": "660.1", "type": "APR-DRG"}], "standard_charges": [{"minimum": 4768.38, "maximum": 4768.38, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 4768.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation, Moderate", "code_information": [{"code": "660.2", "type": "APR-DRG"}], 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"inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 9802.37, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Pancreas, Liver And Shunt Procedures, Moderate", "code_information": [{"code": "260.2", "type": "APR-DRG"}], "standard_charges": [{"minimum": 10681.47, "maximum": 10681.47, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 10681.47, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Pancreas, Liver And Shunt Procedures, Severe", "code_information": [{"code": "260.4", "type": "APR-DRG"}], "standard_charges": [{"minimum": 34891.48, "maximum": 34891.48, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 34891.48, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Respiratory And Chest Procedures, Major", "code_information": [{"code": "120.3", "type": "APR-DRG"}], "standard_charges": [{"minimum": 12521.23, "maximum": 12521.23, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 12521.23, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Respiratory And Chest Procedures, Minor", "code_information": [{"code": "120.1", "type": "APR-DRG"}], "standard_charges": [{"minimum": 8680.44, "maximum": 8680.44, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 8680.44, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Respiratory And Chest Procedures, Moderate", "code_information": [{"code": "120.2", "type": "APR-DRG"}], "standard_charges": [{"minimum": 8879.92, "maximum": 8879.92, "setting": 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{"description": "Major Respiratory Infections And Inflammations, Minor", "code_information": [{"code": "137.1", "type": "APR-DRG"}], "standard_charges": [{"minimum": 2955.81, "maximum": 2955.81, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 2955.81, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Respiratory Infections And Inflammations, Moderate", "code_information": [{"code": "137.2", "type": "APR-DRG"}], "standard_charges": [{"minimum": 4237.91, "maximum": 4237.91, "setting": "inpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 4237.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Major Respiratory Infections And Inflammations, Severe", "code_information": [{"code": "137.4", "type": "APR-DRG"}], "standard_charges": [{"minimum": 11430.52, "maximum": 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"standard_charge_dollar": 244.58, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 651.35, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT AGT GNTYP ALYS SARSCOV2", "code_information": [{"code": "87913", "type": "CPT"}], "standard_charges": [{"minimum": 257.45, "maximum": 617.88, "setting": "outpatient", "payers_information": [{"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 617.88, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 257.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 270.32, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT AGT HIV GNRJ SEQ ALYS", "code_information": [{"code": "219U", "type": "CPT"}], "standard_charges": 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{"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 88.78, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT DS BACT&FNG GRAM POS", "code_information": [{"code": "141U", "type": "CPT"}], "standard_charges": [{"minimum": 29.83, "maximum": 376.2, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 38.25, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 376.2, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 164.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 29.83, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 33.34, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 88.78, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT DS BACT&FNG ORG ID 6+", "code_information": [{"code": "86U", "type": "CPT"}], "standard_charges": [{"minimum": 17.39, "maximum": 480.0, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 22.3, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 480.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 210.0, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 17.39, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 19.44, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 51.76, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT DS BCT QUAN ANTMCRB SC", "code_information": [{"code": "311U", "type": "CPT"}], "standard_charges": [{"minimum": 7.35, "maximum": 21.88, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 9.43, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 19.39, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 8.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 7.35, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 8.22, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 21.88, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT DS BCT/VIRAL TRAIL IP10", "code_information": [{"code": "351U", "type": "CPT"}], "standard_charges": [{"minimum": 85.0, "maximum": 625.2, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 109.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 625.2, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 273.53, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of 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"fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 121.24, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 135.5, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 360.85, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "NFCT DS BV&VAGINITIS AMP PRB", "code_information": [{"code": "352U", "type": "CPT"}], "standard_charges": [{"minimum": 121.24, "maximum": 360.85, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 155.47, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 342.31, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": 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{"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 5144.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 5383.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 11485.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL ATRESIA, SINGLE STAGE", "code_information": [{"code": "69320", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "gross_charge": 31181.0, "discounted_cash": 18708.6, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4608.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12393.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR JOINT, SECONDARY BY SOFT TISSUE STABILIZATION (EG, TENDON TRANSFER, TENDON GRAFT OR WEAVE, OR TENODESIS) WITH OR 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"type": "CPT"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4608.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12393.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": 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cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 30.18, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 30.18, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 26.17, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 58.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOTE E/M NEW PT 20MINS", "code_information": [{"code": "G9482", "type": "HCPCS"}], "standard_charges": [{"minimum": 49.87, "maximum": 112.11, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 57.51, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", 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{"description": "REMOVE IMPACTED EAR WAX UNI", "code_information": [{"code": "69209", "type": "CPT"}], "standard_charges": [{"minimum": 47.31, "maximum": 129.46, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 52.26, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 129.46, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 56.64, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 47.31, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 49.51, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 105.62, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE IMPLANT OF EYE", "code_information": [{"code": "65920", "type": "CPT"}], "standard_charges": [{"minimum": 849.94, "maximum": 4931.74, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1920.77, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 4931.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 849.94, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2157.63, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1738.8, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1819.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3881.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE IN/EX HEM GRP & FISS", "code_information": [{"code": "46257", "type": "CPT"}], "standard_charges": [{"minimum": 939.93, "maximum": 5942.11, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2226.97, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 5942.11, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 939.93, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2599.67, "methodology": "fee 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"Medicaid", "standard_charge_dollar": 939.93, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2599.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2015.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2109.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 4500.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE INFECTED SKULL BONE", "code_information": [{"code": "61501", "type": "CPT"}], "standard_charges": [{"minimum": 1028.06, "maximum": 2295.21, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1135.65, 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"plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE INNER EAR & MASTOID", "code_information": [{"code": "69910", "type": "CPT"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4608.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12393.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE INNER EAR LESION", "code_information": [{"code": "69970", "type": "CPT"}], 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INTESTINAL ALLOGRAFT", "code_information": [{"code": "44137", "type": "CPT"}], "standard_charges": [{"minimum": 1405.56, "maximum": 3137.99, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1552.65, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1405.56, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1470.93, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3137.99, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE INTRA-AORTIC BALLOON", "code_information": [{"code": "33974", "type": "CPT"}], "standard_charges": [{"minimum": 799.64, "maximum": 1785.24, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 883.32, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 799.64, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 836.83, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1785.24, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE INTRACORPOREAL DEVICE", "code_information": [{"code": "33980", "type": "CPT"}], "standard_charges": [{"minimum": 1606.09, "maximum": 3585.7, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1774.17, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1606.09, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1680.8, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3585.7, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE INTRVAS FOREIGN BODY", "code_information": [{"code": "37197", "type": "CPT"}], "standard_charges": [{"minimum": 1118.22, "maximum": 6745.66, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2632.72, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6745.66, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1118.22, "methodology": "fee 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"Commercial", "standard_charge_dollar": 8604.53, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1533.49, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3764.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 3283.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 3436.5, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 7331.19, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE JAW JOINT CARTILAGE", "code_information": [{"code": "21060", "type": "CPT"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "setting": "outpatient", 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"facility"}]}, {"description": "REMOVE KIDNEY LIVING DONOR", "code_information": [{"code": "50320", "type": "CPT"}], "standard_charges": [{"minimum": 1346.67, "maximum": 3006.53, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1487.61, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1346.67, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1409.31, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3006.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE KIDNEY OPEN", "code_information": [{"code": "50220", "type": "CPT"}], "standard_charges": [{"minimum": 939.73, "maximum": 2098.0, "setting": "outpatient", 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"plan_name": "Commercial", "standard_charge_dollar": 6850.1, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1088.27, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2996.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2354.21, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2463.71, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5255.9, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE KNEE JOINT LINING", "code_information": [{"code": "27335", "type": "CPT"}], "standard_charges": [{"minimum": 2398.52, "maximum": 15140.11, "setting": "outpatient", 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"standard_charge_dollar": 1360.92, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1231.99, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1289.3, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 2750.5, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE LUNG CATHETER", "code_information": [{"code": "32552", "type": "CPT"}], "standard_charges": [{"minimum": 223.75, "maximum": 1329.48, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 598.98, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 1329.48, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 223.75, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 581.65, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 542.24, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 567.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1210.58, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE LUNG FOREIGN BODY", "code_information": [{"code": "32151", "type": "CPT"}], "standard_charges": [{"minimum": 893.86, "maximum": 1995.59, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 987.4, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 893.86, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 935.43, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1995.59, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE LUNG PNEUMONECTOMY", "code_information": [{"code": "32440", "type": "CPT"}], "standard_charges": [{"minimum": 1399.99, "maximum": 3125.55, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1546.5, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1399.99, "methodology": "fee 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"standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE MASTOID AIR CELLS", "code_information": [{"code": "69670", "type": "CPT"}], "standard_charges": [{"minimum": 1954.22, "maximum": 12393.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 4608.0, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 12393.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE MAXILLA CYST COMPLEX", "code_information": [{"code": "21048", "type": "CPT"}], "standard_charges": [{"minimum": 1932.03, "maximum": 12393.38, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": 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"69676", "type": "CPT"}], "standard_charges": [{"minimum": 886.62, "maximum": 6813.65, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2488.33, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 6813.65, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 886.62, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 2980.97, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2252.59, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2357.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5029.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE MUTI-COMP PENIS PROS", "code_information": [{"code": "54406", "type": "CPT"}], "standard_charges": [{"minimum": 1142.9, "maximum": 7377.74, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 2867.61, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 7377.74, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1142.9, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 3227.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 2595.94, "methodology": "fee 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"Advantage", "standard_charge_dollar": 93.77, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 98.13, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 209.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE NASAL FOREIGN BODY", "code_information": [{"code": "30320", "type": "CPT"}], "standard_charges": [{"minimum": 420.64, "maximum": 3227.45, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1281.87, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 3227.45, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 420.64, "methodology": "fee schedule"}, 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"standard_charge_dollar": 12393.38, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicaid", "standard_charge_dollar": 1954.22, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 5422.11, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 4171.46, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 4365.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 9313.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE PART LUMBAR VERTEBRA", "code_information": [{"code": "22114", "type": "CPT"}], "standard_charges": [{"minimum": 1005.43, "maximum": 2244.69, "setting": "outpatient", "payers_information": 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"blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 2488.1, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 5307.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE PART THORAX VERTEBRA", "code_information": [{"code": "22101", "type": "CPT"}], "standard_charges": [{"minimum": 5144.48, "maximum": 15140.11, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 5682.85, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Commercial", "standard_charge_dollar": 15140.11, "methodology": "fee schedule"}, {"payer_name": "Community First", "plan_name": "Medicare Advantage", "standard_charge_dollar": 6623.8, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 5144.48, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 5383.76, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 11485.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE PART THORAX VERTEBRA", "code_information": [{"code": "22112", "type": "CPT"}], "standard_charges": [{"minimum": 993.34, "maximum": 2217.7, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1097.3, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 993.34, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1039.55, "methodology": "fee 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{"description": "REMOVE PENIS & NODES", "code_information": [{"code": "54130", "type": "CPT"}], "standard_charges": [{"minimum": 1070.52, "maximum": 2390.0, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1182.55, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1070.52, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1120.31, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 2390.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE PENIS & NODES", "code_information": [{"code": "54135", "type": "CPT"}], "standard_charges": [{"minimum": 1356.28, "maximum": 3027.97, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1498.22, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 1356.28, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 1419.36, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 3027.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REMOVE PHARYNX FOREIGN BODY", "code_information": [{"code": "42809", "type": "CPT"}], "standard_charges": [{"minimum": 312.69, "maximum": 843.22, "setting": "outpatient", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 345.41, "methodology": "fee schedule"}, {"payer_name": "Community First", 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{"payer_name": "blue cross blue shield of texas", "plan_name": "Advantage", "standard_charge_dollar": 675.89, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "HMO", "standard_charge_dollar": 707.33, "methodology": "fee schedule"}, {"payer_name": "blue cross blue shield of texas", "plan_name": "Traditional", "standard_charge_dollar": 1508.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD", "code_information": [{"code": "43255", "type": "CPT"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 564.97, "maximum": 4026.94, "gross_charge": 7169.0, "discounted_cash": 4301.4, "setting": "both", "payers_information": [{"payer_name": "Blue cross blue shield of texas", "plan_name": "PPO", "standard_charge_dollar": 1479.53, "methodology": "fee 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