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"272", "type": "RC"}], "standard_charges": [{"gross_charge": 9.41, "discounted_cash": 5.65, "setting": "both", "billing_class": "facility"}]}, {"description": "COVER LIGHT HANDLE ST FLEX LHC1001", "code_information": [{"code": "LHC1001", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 3.68, "discounted_cash": 2.21, "setting": "both", "billing_class": "facility"}]}, {"description": "COVER PLASTIC MAYO STAND 22/CS BXT8339", "code_information": [{"code": "BXT8339", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 8.4, "discounted_cash": 5.04, "setting": "both", "billing_class": "facility"}]}, {"description": "COVER POST SURG .54IN RED STRAIGHT FOR STEINMANN PINN AND K-WIRE LATEX FREE STER C-054", "code_information": [{"code": "C-054", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 9.41, "discounted_cash": 5.65, "setting": "both", "billing_class": "facility"}]}, {"description": 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"standard_charge_dollar": 48.24, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 55.73, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 72.01, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 48.24, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 71.85, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Direct admission of patient for hospital observation care G0379", "code_information": [{"code": "G0379", "type": "HCPCS"}, {"code": "16017298", "type": "CDM"}, {"code": "762", "type": "RC"}], "standard_charges": [{"minimum": 585.19, "maximum": 822.17, "gross_charge": 253.0, "discounted_cash": 151.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 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"plan_name": "City of Dallas PPO", "standard_charge_dollar": 224.11, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 166.84, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 166.84, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 249.01, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 166.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Drug test any number of drug classes instrumented chemistry analyzers immunoassay 80307", "code_information": [{"code": "80307", "type": "CPT"}, {"code": "43026364", "type": "CDM"}, {"code": "301", "type": "RC"}], "standard_charges": [{"minimum": 77.68, "maximum": 214.97, "gross_charge": 319.0, "discounted_cash": 191.4, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": 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"inpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 11867.67, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 11867.67, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 19235.61, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 18274.84, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 12888.87, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 17312.05, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 12888.87, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 12888.87, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 14313.4, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 19235.61, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 12888.87, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 24851.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC", "code_information": [{"code": "148", "type": "MS-DRG"}], "standard_charges": [{"minimum": 4817.3, "maximum": 10474.0, "setting": "inpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 4817.3, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 4817.3, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 7808.08, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 7418.08, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 5231.82, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 7027.27, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 5231.82, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 5231.82, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 6032.51, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 7808.08, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 5231.82, "methodology": "fee 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55.5, "setting": "both", "billing_class": "facility"}]}, {"description": "EASY CONNECT HANDLE SMALL 697.705", "code_information": [{"code": "697.705", "type": "CDM"}], "standard_charges": [{"gross_charge": 1320.0, "discounted_cash": 792.0, "setting": "both", "billing_class": "facility"}]}, {"description": "EASYSPRAY SET 600065", "code_information": [{"code": "600065", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 192.44, "discounted_cash": 115.46, "setting": "both", "billing_class": "facility"}]}, {"description": "EBV DNA QT. 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LESION OF MUCOSA/SUBMUCOSA MOUTH W/SIMPLE REPAIR 40812", "code_information": [{"code": "40812", "type": "CPT"}, {"code": "1587118", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1389.42, "maximum": 3361.0, "gross_charge": 3924.0, "discounted_cash": 2354.4, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1389.42, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2359.84, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "EXC. OF LESION OF MUCOSA/SUBMUCOSA VESTIBLUE MOUTH W/O REPARI COMPLEX W/EXC. 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OF NEUROMA HAND OR FOOT EA. ADD. NERVE EXCEPT SAME DIGIT 64783", "code_information": [{"code": "64783", "type": "CPT"}, {"code": "8125375", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1673.0, "maximum": 3538.0, "gross_charge": 13205.0, "discounted_cash": 7923.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1673.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1673.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3538.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3184.2, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3538.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "EXC. OF SKIN AND SUBCU. TISSUE FOR HIDRADENITIS; PERIANAL/PERINEAL/UMBILICAL W/COMPLEX REPAIR 11471", "code_information": [{"code": "11471", "type": "CPT"}, {"code": "18959518", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1673.0, "maximum": 4391.53, "gross_charge": 1555.0, "discounted_cash": 933.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1673.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1673.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3538.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3184.2, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2588.78, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3538.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2370.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4391.53, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "EXC. 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"plan_name": "HPN", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 363.28, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 5469.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 634.22, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "EXCISION MALIGNANT LESION W/MARGIN TRUNK/ARMS/LEGS 0.6CM TO 1.0CM 11601", "code_information": [{"code": "11601", "type": "CPT"}, {"code": "1795861", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 641.0, "maximum": 3361.0, "gross_charge": 1928.0, "discounted_cash": 1156.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", 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992.16, "discounted_cash": 595.3, "setting": "both", "billing_class": "facility"}]}, {"description": "HAMMER 2942049 DL SLAP HAMMER 2942049", "code_information": [{"code": "2942049", "type": "CDM"}], "standard_charges": [{"gross_charge": 1137.5, "discounted_cash": 682.5, "setting": "both", "billing_class": "facility"}]}, {"description": "HAMMER 350 GRAMS 399.41.99", "code_information": [{"code": "399.41.99", "type": "CDM"}], "standard_charges": [{"gross_charge": 1198.6, "discounted_cash": 719.16, "setting": "both", "billing_class": "facility"}]}, {"description": "HAMMER 907-405 TANGENT SLAP 907-405", "code_information": [{"code": "907-405", "type": "CDM"}], "standard_charges": [{"gross_charge": 1142.05, "discounted_cash": 685.23, "setting": "both", "billing_class": "facility"}]}, {"description": "HAMMER TECH INSTRUMENT KIT MEDIUM CD-HT-5540-S", "code_information": [{"code": "CD-HT-5540-S", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 1980.0, 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"plan_name": "PPO", "standard_charge_dollar": 15222.7, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 10200.01, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 19082.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC", "code_information": [{"code": "514", "type": "MS-DRG"}], "standard_charges": [{"minimum": 6084.67, "maximum": 12261.0, "setting": "inpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 6084.67, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 6084.67, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 9862.29, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 9369.69, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 6608.25, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 8876.06, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 6608.25, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 6608.25, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 7061.77, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 9862.29, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 6608.25, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 12261.0, 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"methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5060.32, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "HANDHELD RETRACTOR-CURVED FOR SYNFIX-LR 03.802.400", "code_information": [{"code": "3.802.400", "type": "CDM"}], "standard_charges": [{"gross_charge": 852.8, "discounted_cash": 511.68, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 1001033 FLINX STAMP HANDLE 1001033", "code_information": [{"code": "1001033", "type": "CDM"}], "standard_charges": [{"gross_charge": 475.8, "discounted_cash": 285.48, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 2670003 WAVE DISTRACTION HANDLE 2670003", "code_information": [{"code": "2670003", "type": "CDM"}], "standard_charges": [{"gross_charge": 558.09, "discounted_cash": 334.85, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 2942022 ACCESS HANDLE LEFT 2942022", "code_information": [{"code": "2942022", "type": "CDM"}], "standard_charges": [{"gross_charge": 910.0, "discounted_cash": 546.0, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 2942050 ACCESS HANDLE RIGHT 2942050", "code_information": [{"code": "2942050", "type": "CDM"}], "standard_charges": [{"gross_charge": 910.0, "discounted_cash": 546.0, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 5480140V ADJUSTABLE DRIVER 5480140V", "code_information": [{"code": "5480140V", "type": "CDM"}], "standard_charges": [{"gross_charge": 1029.6, "discounted_cash": 617.76, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 6650250 UNIVERSAL 6650250", "code_information": [{"code": "6650250", "type": "CDM"}], "standard_charges": [{"gross_charge": 901.81, "discounted_cash": 541.09, "setting": "both", "billing_class": 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9339012 QUICK CONNECT EGG BLUE 9339012", "code_information": [{"code": "9339012", "type": "CDM"}], "standard_charges": [{"gross_charge": 1525.68, "discounted_cash": 915.41, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE 9563080 MAST MIDLF BLADE HANDLE 9563080", "code_information": [{"code": "9563080", "type": "CDM"}], "standard_charges": [{"gross_charge": 1365.0, "discounted_cash": 819.0, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE C6908 MARKER C6908", "code_information": [{"code": "C6908", "type": "CDM"}], "standard_charges": [{"gross_charge": 387.0, "discounted_cash": 232.2, "setting": "both", "billing_class": "facility"}]}, {"description": "HANDLE CATH SINUS GUIDE FOR RELIEVA FLEX SINUS GUIDE CATH RELIEVA SIDEKICK STRL", "code_information": [{"code": "SDKKLP", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 198.0, "discounted_cash": 118.8, "setting": "both", "billing_class": 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"PPO", "standard_charge_dollar": 235.1, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ CALCITRIOL PER 0.1 MCG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0636", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.79, "maximum": 0.79, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.79, "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": 1.19, "maximum": 1.38, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.19, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.38, "methodology": "fee 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CLADRIBINE PER 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9065", "type": "HCPCS"}], "standard_charges": [{"minimum": 15.87, "maximum": 19.1, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 15.87, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 19.1, "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": 121.77, "maximum": 144.62, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 121.77, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 144.62, "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": 1001.43, "maximum": 1269.4, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1001.43, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1269.4, "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": 13.2, "maximum": 16.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 13.2, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 16.01, "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": 15.13, "maximum": 17.93, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 15.13, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 17.93, "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": 3.7, "maximum": 3.7, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3.7, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ CYCLOPHOSPHAMD AUROMEDIC", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9071", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.68, "maximum": 4.41, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.68, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.41, "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": 222.61, "maximum": 259.85, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 222.61, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 259.85, "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": 3193324.48, "maximum": 3193324.48, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3193324.48, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ DESMOPRESSIN ACETATE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2597", "type": "HCPCS"}], "standard_charges": [{"minimum": 6.0, "maximum": 7.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 6.0, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 7.01, "methodology": "fee 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"methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DIAGNOSTIC/THERAPEUTIC AGENT PARAVERTEBRAL FACET JOINT W/ IMAGE GUIDANCE LUMBAR/SACRAL 64493", "code_information": [{"code": "64493", "type": "CPT"}, {"code": "1582416", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 830.42, "maximum": 3361.0, "gross_charge": 3924.0, "discounted_cash": 2354.4, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 830.42, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1448.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DIHYDROERGOTAMINE MESYLT", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1110", "type": "HCPCS"}], "standard_charges": [{"minimum": 53.03, "maximum": 53.03, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 53.03, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DOBUTAMINE HCL/250 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1250", "type": "HCPCS"}], "standard_charges": [{"minimum": 11.2, "maximum": 11.2, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 11.2, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ DUPUYTREN CORD W/ENZYME", "code_information": [{"code": "20527", "type": "CPT"}], "standard_charges": [{"minimum": 269.84, "maximum": 3361.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 269.84, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 462.21, "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": 31.71, "maximum": 31.71, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 31.71, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ EFGARTIGIMOD 2MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9332", "type": "HCPCS"}], "standard_charges": [{"minimum": 30.66, "maximum": 36.6, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 30.66, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 36.6, "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": 26.52, "maximum": 47.02, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 26.52, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 47.02, "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": 34.62, "maximum": 39.96, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 34.62, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 39.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ENOXAPARIN SODIUM", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1650", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.75, "maximum": 0.75, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.75, "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": 51.42, "maximum": 51.42, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 51.42, "methodology": "case rate"}], "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": 0.41, "maximum": 0.53, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.41, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.53, "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": 356.06, "maximum": 424.62, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 356.06, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 424.62, "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": 125.94, "maximum": 125.94, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 125.94, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ FERRIC CARBOXYMALTOS 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1439", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.05, "maximum": 1.28, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.05, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FERRIC PYROPHOSPHATE CIT", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1443", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.03, "maximum": 0.03, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.03, "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": 0.95, "maximum": 1.12, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.95, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.12, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FOLLITROPIN ALFA 75 IU", "code_information": [{"code": "S0126", "type": "HCPCS"}], "standard_charges": [{"minimum": 253.59, "maximum": 253.59, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 253.59, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ FOLLITROPIN BETA 75 IU", "code_information": [{"code": "S0128", "type": "HCPCS"}], "standard_charges": [{"minimum": 228.38, "maximum": 228.38, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 228.38, "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": 602.35, "maximum": 677.32, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 677.32, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 602.35, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ GADOTERATE MEGLUMI 0.1ML", "code_information": [{"code": "A9575", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.14, "maximum": 0.14, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ GANIRELIX ACETAT 250 MCG", "code_information": [{"code": "S0132", "type": "HCPCS"}], "standard_charges": [{"minimum": 210.25, "maximum": 210.25, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 210.25, "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": 4.05, "maximum": 4.21, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 4.05, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.21, "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": 107.11, "maximum": 127.79, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 107.11, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 127.79, "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": 2588.69, "maximum": 2588.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2588.69, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ GLUCAGON HCL, FRESENIUS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1611", "type": "HCPCS"}], "standard_charges": [{"minimum": 123.24, "maximum": 126.27, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 123.24, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 126.27, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HEPARIN SODIUM PER 10 U", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1642", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.02, "maximum": 0.02, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.02, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HEPARIN SODIUM PER 1000U", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1644", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.32, "maximum": 0.32, "estimated_discounted_cash": 15.22, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.32, "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": 4.15, "maximum": 5.91, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 4.15, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ HERZUMA 10 MG", "code_information": [{"code": "Q5113", "type": "HCPCS"}], "standard_charges": [{"minimum": 23.01, "maximum": 53.35, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 53.35, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 23.01, "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": 1.38, "maximum": 1.57, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.38, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.57, "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": 10.09, "maximum": 17.38, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 17.38, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 10.09, "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": 2.34, "maximum": 2.8, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.34, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.8, "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": 2467.15, "maximum": 2883.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2467.15, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2883.69, "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": 60.66, "maximum": 71.23, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 60.66, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 71.23, "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": 16.56, "maximum": 19.84, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 16.56, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 19.84, "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": 45.76, "maximum": 54.25, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 45.76, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 54.25, "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": 2.27, "maximum": 3.1, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.27, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3.1, "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": 0.69, "maximum": 0.82, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.69, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.82, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ LEVOCARNITINE PER 1 GM", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1955", "type": "HCPCS"}], "standard_charges": [{"minimum": 40.4, "maximum": 40.4, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 40.4, "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": 0.05, "maximum": 0.09, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.05, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.09, "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": 191.71, "maximum": 223.37, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 191.71, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 223.37, "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": 38.23, "maximum": 44.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 38.23, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 44.69, "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": 2796.7, "maximum": 3315.04, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2796.7, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3315.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MAGNESIUM SULFATE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3475", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.87, "maximum": 0.87, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.87, "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": 160.41, "maximum": 200.93, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 160.41, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 200.93, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MENOTROPINS 75 IU", "code_information": [{"code": "S0122", "type": "HCPCS"}], "standard_charges": [{"minimum": 245.08, "maximum": 245.08, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 245.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MEPIVACAINE HCL/10 ML", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0670", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.8, "maximum": 2.8, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.8, "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": 0.25, "maximum": 0.33, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.25, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.33, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MIDAZOLAM HYDROCHLORIDE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2250", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.19, "maximum": 0.19, "estimated_discounted_cash": 6.56, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.19, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MILRINONE LACTATE / 5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2260", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.02, "maximum": 2.02, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.02, "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": 223.91, "maximum": 259.17, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 223.91, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 259.17, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MORPHINE PF EPID ITHC", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2274", "type": "HCPCS"}], "standard_charges": [{"minimum": 12.76, "maximum": 12.76, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 12.76, "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": 601.59, "maximum": 717.86, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 601.59, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 717.86, "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": 6.06, "maximum": 7.16, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 7.16, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 6.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MULTIHANCE", "code_information": [{"code": "A9577", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.07, "maximum": 2.07, "estimated_discounted_cash": 126.23, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.07, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MULTIHANCE MULTIPACK", "code_information": [{"code": "A9578", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.08, "maximum": 2.08, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ MVASI 10 MG", "code_information": [{"code": "Q5107", "type": "HCPCS"}], "standard_charges": [{"minimum": 25.58, "maximum": 31.75, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 25.58, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 31.75, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ NALBUPHINE HYDROCHLORIDE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2300", "type": "HCPCS"}], "standard_charges": [{"minimum": 3.28, "maximum": 3.28, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ NALOXONE HYDROCHLORIDE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2310", "type": "HCPCS"}], "standard_charges": [{"minimum": 10.88, "maximum": 10.88, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 10.88, "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": 178.81, "maximum": 209.32, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 178.81, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 209.32, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ OCTAFLUOROPROPANE MIC,ML", "code_information": [{"code": "Q9956", "type": "HCPCS"}], "standard_charges": [{"minimum": 48.64, "maximum": 48.64, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 48.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ OGIVRI 10 MG", "code_information": [{"code": "Q5114", "type": "HCPCS"}], "standard_charges": [{"minimum": 45.65, "maximum": 59.88, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 59.88, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 45.65, "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": 360.09, "maximum": 429.91, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 360.09, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 429.91, "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": 2173075.91, "maximum": 3417016.24, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2173075.91, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3417016.24, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ ONTRUZANT 10 MG", "code_information": [{"code": "Q5112", "type": "HCPCS"}], "standard_charges": [{"minimum": 32.57, "maximum": 47.48, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 32.57, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 47.48, "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": 104.95, "maximum": 112.42, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 104.95, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 112.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEGFILGRASTIM-BMEZ 0.5MG", "code_information": [{"code": "Q5120", "type": "HCPCS"}], "standard_charges": [{"minimum": 331.57, "maximum": 395.3, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 331.57, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 395.3, "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": 54.8, "maximum": 64.31, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 54.8, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 64.31, "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": 9.23, "maximum": 11.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 9.23, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 11.01, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PEMETREXED (BLUEPOINT)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9322", "type": "HCPCS"}], "standard_charges": [{"minimum": 10.96, "maximum": 10.96, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 10.96, "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": 1.36, "maximum": 2.6, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.36, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.6, "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": 9.52, "maximum": 22.75, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 9.52, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 22.75, "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": 8.07, "maximum": 9.89, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 9.89, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 8.07, "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": 3.46, "maximum": 5.67, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3.46, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5.67, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PERFLUTREN LIP MICROS,ML", "code_information": [{"code": "Q9957", "type": "HCPCS"}], "standard_charges": [{"minimum": 48.64, "maximum": 48.64, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 48.64, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PHENYLEPHRINE HCL 20 MCG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2371", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.01, "maximum": 0.01, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.01, "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": 30.41, "maximum": 36.25, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 30.41, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 36.25, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ POTASSIUM CHLORIDE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3480", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.13, "maximum": 0.13, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.13, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PROGESTERONE PER 50 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2675", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.01, "maximum": 1.01, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.01, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PROHANCE MULTIPACK", "code_information": [{"code": "A9576", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.6, "maximum": 1.6, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.6, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ PROTAMINE SULFATE/10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2720", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.9, "maximum": 0.9, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.9, "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": 2.02, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.02, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ RETACRIT ESRD ON DIALYSI", "code_information": [{"code": "Q5105", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.72, "maximum": 0.83, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.72, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ RETACRIT NON-ESRD USE", "code_information": [{"code": "Q5106", "type": "HCPCS"}], "standard_charges": [{"minimum": 7.18, "maximum": 8.27, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 7.18, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 8.27, "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": 14.35, "maximum": 23.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 14.35, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 23.0, "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": 11.65, "maximum": 13.85, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 11.65, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 13.85, "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": 35.61, "maximum": 42.33, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 35.61, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 42.33, "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": 11156.98, "maximum": 11156.98, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 11156.98, "methodology": "case rate"}], "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": 29.21, "maximum": 34.95, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 29.21, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 34.95, "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": 32.42, "maximum": 38.65, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 32.42, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 38.65, "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": 21.85, "maximum": 21.85, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 21.85, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ RUXIENCE, 10 MG", "code_information": [{"code": "Q5119", "type": "HCPCS"}], "standard_charges": [{"minimum": 19.39, "maximum": 25.43, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 19.39, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 25.43, "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": 514.87, "maximum": 610.96, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 514.87, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 610.96, "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": 39.91, "maximum": 47.58, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 39.91, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 47.58, "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": 104.5, "maximum": 122.73, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 104.5, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 122.73, "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": 91.65, "maximum": 109.65, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 91.65, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 109.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ SULF HEXA LIPID MICROSPH", "code_information": [{"code": "Q9950", "type": "HCPCS"}], "standard_charges": [{"minimum": 21.41, "maximum": 21.41, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 21.41, "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": 63.88, "maximum": 75.58, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 63.88, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 75.58, "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": 0.39, "maximum": 0.47, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.39, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.47, "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": 29.41, "maximum": 35.22, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 29.41, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 35.22, "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": 1.74, "maximum": 1.98, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.74, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.98, "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": 34.79, "maximum": 41.3, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 34.79, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 41.3, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TESTOSTERO ENANTHATE 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3121", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.05, "maximum": 0.05, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.05, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TESTOSTERONE CYPIONATE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1071", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.03, "maximum": 0.03, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.03, "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": 17.02, "maximum": 27.87, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 17.02, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 27.87, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ THEOPHYLLINE PER 40 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2810", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.47, "maximum": 0.47, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.47, "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": 167.14, "maximum": 191.82, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 167.14, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 191.82, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TOFERSEN INTRATHEC 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1304", "type": "HCPCS"}], "standard_charges": [{"minimum": 144.23, "maximum": 144.23, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 144.23, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ TRASTUZUMAB EXCL BIOSIMI", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9355", "type": "HCPCS"}], "standard_charges": [{"minimum": 76.54, "maximum": 92.09, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 76.54, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 92.09, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ TRIAMCINOLONE ACE XR 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3304", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.72, "maximum": 16.72, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 16.72, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ TRUXIMA 10 MG", "code_information": [{"code": "Q5115", "type": "HCPCS"}], "standard_charges": [{"minimum": 29.62, "maximum": 42.89, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 29.62, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 42.89, "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": 64.29, "maximum": 64.29, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 64.29, "methodology": "case rate"}], "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": 0.27, "maximum": 0.64, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.27, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.64, "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": 405.43, "maximum": 405.43, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 405.43, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ XIPERE 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3299", "type": "HCPCS"}], "standard_charges": [{"minimum": 46.46, "maximum": 72.87, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 46.46, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 72.87, "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": 5.55, "maximum": 5.55, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.55, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ, ACETAMINOPHEN (B BRAUN)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0136", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.05, "maximum": 0.06, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.05, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ACETAMINOPHEN (HIKMA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0137", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.06, "maximum": 0.08, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.06, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ACETAMINOPHEN (NOS)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0131", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.08, "maximum": 0.08, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.08, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ADO-TRASTUZUMAB EMT 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9354", "type": "HCPCS"}], "standard_charges": [{"minimum": 36.75, "maximum": 43.71, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 36.75, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 43.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ADUCANUMAB-AVWA, 2 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0172", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.72, "maximum": 5.72, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.72, "methodology": "case rate"}], "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": 1.39, "maximum": 1.65, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.39, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ALFENTANIL HCL, 500MCG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0216", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.76, "maximum": 2.76, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.76, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, AMIODARONE (NEXTERONE)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0283", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.61, "maximum": 4.61, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.61, "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": 8.68, "maximum": 8.68, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 8.68, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ, AMIVANTAMAB-VMJW", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9061", "type": "HCPCS"}], "standard_charges": [{"minimum": 19.11, "maximum": 22.79, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 19.11, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 22.79, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, APONVIE, 1 MG", "code_information": [{"code": "C9145", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.8, "maximum": 3.19, 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"plan_name": "Medicare Adv HMO", "standard_charge_dollar": 48.96, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 56.67, "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": 80.26, "maximum": 94.19, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 80.26, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 94.19, "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": [{"minimum": 32.53, "maximum": 37.83, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 32.53, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 37.83, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BEZLOTOXUMAB, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0565", "type": "HCPCS"}], "standard_charges": [{"minimum": 38.13, "maximum": 45.42, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 38.13, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 45.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BIORPHEN, 20 MICROGRAMS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2372", "type": "HCPCS"}], "standard_charges": 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"facility"}]}, {"description": "INJ, BROLUCIZUMAB-DBLL, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0179", "type": "HCPCS"}], "standard_charges": [{"minimum": 311.42, "maximum": 363.94, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 311.42, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 363.94, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, BUPIVACAINE (POSIMIR)", "code_information": [{"code": "C9144", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.48, "maximum": 0.48, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.48, "methodology": "case rate"}], "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, "estimated_discounted_cash": 2.57, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.01, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.02, "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": 21.63, "maximum": 33.43, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 21.63, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 33.43, "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": 0.05, "maximum": 0.05, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.05, "methodology": "case rate"}], "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": 4.73, "maximum": 5.8, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 4.73, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5.8, "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": 2.08, "maximum": 3.26, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.08, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CIMERLI, 0.1 MG", "code_information": [{"code": "Q5128", "type": "HCPCS"}], "standard_charges": [{"minimum": 244.95, "maximum": 409.9, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 244.95, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 409.9, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CLINDAMYCIN (BAXTER)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0737", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.11, "maximum": 2.96, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.11, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.96, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, CLINDAMYCIN PHOSP 300MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0736", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.17, "maximum": 2.3, "estimated_discounted_cash": 64.4, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.17, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.3, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, DAPTOMYCIN (HOSPIRA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0877", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.06, "maximum": 0.07, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.06, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.07, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, DECITABINE (SUN PHARMA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0893", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.03, "maximum": 2.42, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.03, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.42, "methodology": "fee 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"standard_charge_dollar": 7.15, "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": 62.81, "maximum": 74.96, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 62.81, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 74.96, "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": 1.8, "maximum": 1.94, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.8, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.94, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, EPIRUBICIN HCL, 2 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9178", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.65, "maximum": 1.65, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ESMOLOL HCL, 10MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1805", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.21, "maximum": 0.28, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.21, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ETELCALCETIDE, 0.1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0606", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.34, "maximum": 3.72, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.34, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3.72, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, ETEPLIRSEN, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1428", "type": "HCPCS"}], "standard_charges": [{"minimum": 168.0, "maximum": 168.0, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 168.0, "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": 171.29, "maximum": 171.29, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 171.29, "methodology": "case rate"}], "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": 8.71, "maximum": 10.39, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 8.71, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 10.39, "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": 33.89, "maximum": 41.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 33.89, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 41.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, FOSAPREPITANT (TEVA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1456", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.2, "maximum": 1.95, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.95, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.2, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, FULVESTRANT (FRESENIUS)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9394", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.05, "maximum": 79.5, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.05, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 79.5, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, FULVESTRANT (TEVA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9393", "type": "HCPCS"}], "standard_charges": [{"minimum": 20.27, "maximum": 31.8, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 20.27, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 31.8, "methodology": "fee 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1.0, "type": "EA"}, "code_information": [{"code": "J1574", "type": "HCPCS"}], "standard_charges": [{"minimum": 57.0, "maximum": 57.0, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 57.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, GRANISETRON, XR, 0.1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1627", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.19, "maximum": 6.59, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.19, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 6.59, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, HEMGENIX, PER TX DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1411", "type": "HCPCS"}], "standard_charges": [{"minimum": 3494311.16, "maximum": 4229400.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3494311.16, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4229400.0, "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": 69.77, "maximum": 83.18, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 69.77, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 83.18, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, INVEGA HAFYERA/TRINZA", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2427", "type": "HCPCS"}], "standard_charges": [{"minimum": 11.65, "maximum": 13.91, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 11.65, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 13.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, INVEGA SUSTENNA, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2426", "type": "HCPCS"}], "standard_charges": [{"minimum": 13.65, "maximum": 16.35, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 13.65, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 16.35, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, IXINITY, 1 I.U.", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7213", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.76, "maximum": 2.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.76, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.01, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, KOVALTRY, 1 I.U.", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7211", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.36, "maximum": 1.62, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.36, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.62, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, LABETALOL HCL, 5MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1920", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.16, "maximum": 0.21, "estimated_discounted_cash": 34.04, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.16, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, LANREOTIDE, (CIPLA) 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1932", "type": "HCPCS"}], "standard_charges": [{"minimum": 42.1, "maximum": 56.97, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 42.1, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 56.97, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, LECANEMAB-IRMB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0174", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.28, "maximum": 2.03, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.28, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.03, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, LENACAPAVIR, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1961", "type": "HCPCS"}], "standard_charges": [{"minimum": 21.05, "maximum": 32.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 21.05, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 32.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, LINEZOLID (HOSPIRA)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2021", "type": "HCPCS"}], "standard_charges": [{"minimum": 15.66, "maximum": 15.71, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 15.71, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 15.66, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, MELPHALAN FLUFENAMI 1MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9247", "type": "HCPCS"}], "standard_charges": [{"minimum": 408.2, "maximum": 573.99, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 408.2, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 573.99, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, MEROPENEM (B. BRAUN)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2184", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.93, "maximum": 2.39, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.93, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.39, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, METRONIDAZOLE, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1836", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.02, "maximum": 0.03, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.02, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.03, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, MICAFUNGIN (PAR PHARM)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2247", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.26, "maximum": 0.45, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.26, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.45, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, MORPHINE (FRESENIUS)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2272", "type": "HCPCS"}], "standard_charges": [{"minimum": 6.96, "maximum": 8.06, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 6.96, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 8.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, MOXIFLOXACIN 100 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2280", "type": "HCPCS"}], "standard_charges": [{"minimum": 11.13, "maximum": 11.13, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 11.13, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, NALOXONE HCL (ZIMHI)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2311", "type": "HCPCS"}], "standard_charges": [{"minimum": 4.91, "maximum": 6.02, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 6.02, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, NITROGLYCERIN, 5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2305", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.38, "maximum": 1.48, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.38, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.48, "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": 1157.1, "maximum": 1157.1, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1157.1, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ, NYVEPRIA", "code_information": [{"code": "Q5122", "type": "HCPCS"}], "standard_charges": [{"minimum": 62.64, "maximum": 101.44, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 62.64, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 101.44, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, OCRIPLASMIN, 0.125 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7316", "type": "HCPCS"}], "standard_charges": [{"minimum": 106.04, "maximum": 106.04, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 106.04, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, OLARATUMAB, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9285", "type": "HCPCS"}], "standard_charges": [{"minimum": 56.0, "maximum": 56.0, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 56.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, OLICERIDINE 0.1 MG", "code_information": [{"code": "C9101", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.25, "maximum": 1.25, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.25, "methodology": "case rate"}], "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": 3.78, "maximum": 4.52, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3.78, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.52, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, PAFOLACIANINE, 0.1 MG", "code_information": [{"code": "A9603", "type": "HCPCS"}], "standard_charges": [{"minimum": 139.45, "maximum": 139.45, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 139.45, "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": 62.1, "maximum": 98.56, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 62.1, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 98.56, "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": 442.91, "maximum": 519.63, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 442.91, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 519.63, "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": 143.34, "maximum": 230.28, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 143.34, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 230.28, "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": 118.6, "maximum": 138.21, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 118.6, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 138.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, PROPOFOL, 10 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2704", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.11, "maximum": 0.11, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.11, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, RELEUKO 1 MCG", "code_information": [{"code": "Q5125", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.5, "maximum": 0.79, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.5, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.79, "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": 5.79, "maximum": 9.09, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.79, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 9.09, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, REMIMAZOLAM, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2249", "type": "HCPCS"}], "standard_charges": [{"minimum": 2.17, "maximum": 2.17, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.17, "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": 28.21, "maximum": 33.44, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 28.21, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 33.44, "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": 9.68, "maximum": 15.06, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 9.68, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 15.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, SCULPTRA, 0.5MG", "code_information": [{"code": "Q2028", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.34, "maximum": 1.34, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.34, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ, SEZABY, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2561", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.52, "maximum": 1.52, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.52, "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": 57.51, "maximum": 68.65, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 57.51, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 68.65, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, STIMUFEND, 0.5 MG", "code_information": [{"code": "Q5127", "type": "HCPCS"}], "standard_charges": [{"minimum": 329.03, "maximum": 523.71, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 329.03, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 523.71, "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": 76.85, "maximum": 92.83, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 76.85, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 92.83, "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": 16.99, "maximum": 20.23, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 16.99, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 20.23, "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": 43.03, "maximum": 51.5, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 43.03, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 51.5, "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": 199.78, "maximum": 232.36, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 199.78, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 232.36, "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": 129.8, "maximum": 155.39, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 129.8, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 155.39, "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": 7.1, "maximum": 9.76, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 7.1, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 9.76, "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": 23.34, "maximum": 23.34, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 23.34, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ, VANCOMYCIN HCL (MYLAN)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3371", "type": "HCPCS"}], "standard_charges": [{"minimum": 5.61, "maximum": 7.12, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.61, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 7.12, "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": 6.12, "maximum": 7.4, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 6.12, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 7.4, "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": 1.8, "maximum": 2.91, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.8, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.91, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ, VEGZELMA, 10 MG", "code_information": [{"code": "Q5129", "type": "HCPCS"}], "standard_charges": [{"minimum": 66.23, "maximum": 104.66, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 66.23, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 104.66, "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": 3270.97, "maximum": 3899.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3270.97, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3899.69, "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": 4719.08, "maximum": 5643.43, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 4719.08, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5643.43, "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": 6.39, "maximum": 8.9, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 6.39, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 8.9, "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": 3217.92, "maximum": 5216.31, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3217.92, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5216.31, "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": 3222.78, "maximum": 6135.13, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3222.78, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 6135.13, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. AIR OR CONTRAST INTO PERITONEAL CAVITY 49400", "code_information": [{"code": "49400", "type": "CPT"}, {"code": "46294621", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1590.0, "maximum": 3361.0, "gross_charge": 3530.0, "discounted_cash": 2118.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "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": 469.88, "maximum": 560.2, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 469.88, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 560.2, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. AVSOLA, 10 MG", "code_information": [{"code": "Q5121", "type": "HCPCS"}], "standard_charges": [{"minimum": 23.31, "maximum": 30.17, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 23.31, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 30.17, "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": 8.49, "maximum": 17.14, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 8.49, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 17.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. BONE SUB MAT. INTO SUBCHONDRAL BONE DEFECT W/IMAGE 0707T", "code_information": [{"code": "707T", "type": "CPT"}, {"code": "46020889", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 2948.97, "maximum": 7101.0, "gross_charge": 3305.0, "discounted_cash": 1983.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 3359.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 3359.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 7101.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 6746.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 6390.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2948.97, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 7101.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. BYOOVIZ, 0.1 MG", "code_information": [{"code": "Q5124", "type": "HCPCS"}], "standard_charges": [{"minimum": 167.39, "maximum": 167.39, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 167.39, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ. CALASPARGASE PEGOL-MKNL", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9118", "type": "HCPCS"}], "standard_charges": [{"minimum": 83.09, "maximum": 83.09, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 83.09, "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": 5.51, "maximum": 6.48, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 5.51, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 6.48, "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": 14.32, "maximum": 14.32, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 14.32, "methodology": "case rate"}], "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": 17.26, "maximum": 19.87, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 17.26, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 19.87, "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": 19.06, "maximum": 22.87, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 19.06, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 22.87, "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": 63.04, "maximum": 75.24, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 63.04, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 75.24, "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": 452.78, "maximum": 539.8, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 452.78, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 539.8, "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": 38.52, "maximum": 45.92, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 38.52, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 45.92, "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": 73.07, "maximum": 85.09, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 73.07, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 85.09, "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": 2.23, "maximum": 2.67, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.23, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.67, "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": 304.17, "maximum": 364.23, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 304.17, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 364.23, "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": 190.79, "maximum": 224.37, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 190.79, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 224.37, "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": 44.98, "maximum": 52.36, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 44.98, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 52.36, "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": 0.68, "maximum": 1.11, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.68, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.11, "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": 583.31, "maximum": 660.67, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 583.31, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 660.67, "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": 0.91, "maximum": 1.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 0.91, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.01, "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": 3.8, "maximum": 4.83, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3.8, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.83, "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": 60.32, "maximum": 75.5, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 60.32, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 75.5, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ. RIABNI, 10 MG", "code_information": [{"code": "Q5123", "type": "HCPCS"}], "standard_charges": [{"minimum": 39.6, "maximum": 49.56, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 39.6, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 49.56, "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": 10.22, "maximum": 11.8, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 10.22, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 11.8, "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": 312.35, "maximum": 369.91, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 312.35, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 369.91, "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": 318.8, "maximum": 373.92, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 318.8, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 373.92, "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": 2.54, "maximum": 2.63, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.54, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.63, "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": 56.2, "maximum": 88.18, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 56.2, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 88.18, "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": 13.51, "maximum": 15.93, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 13.51, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 15.93, "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": 1.59, "maximum": 1.98, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.59, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.98, "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": 2.95, "maximum": 3.48, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2.95, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3.48, "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": 13.23, "maximum": 18.08, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 13.23, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 18.08, "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": 158.01, "maximum": 158.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 158.01, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ., BREXANOLONE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1632", "type": "HCPCS"}], "standard_charges": [{"minimum": 68.46, "maximum": 82.33, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 68.46, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 82.33, "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": 26.37, "maximum": 30.69, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 26.37, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 30.69, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., CERLIPONASE ALFA 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0567", "type": "HCPCS"}], "standard_charges": [{"minimum": 101.76, "maximum": 101.76, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 101.76, "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": 83.82, "maximum": 97.71, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 83.82, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 97.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., COSYNTROPIN, 0.25 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0834", "type": "HCPCS"}], "standard_charges": [{"minimum": 37.26, "maximum": 37.26, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 37.26, "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": 76.99, "maximum": 90.9, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 76.99, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 90.9, "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": 348.89, "maximum": 444.78, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 348.89, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 444.78, "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": 48.62, "maximum": 48.62, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 48.62, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ., ERAVACYCLINE, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0122", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.06, "maximum": 1.06, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.06, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ., EVOMELA, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9246", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.15, "maximum": 18.33, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 16.15, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 18.33, "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": 1.35, "maximum": 1.65, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.35, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.65, "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": 1.74, "maximum": 1.74, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.74, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ., GUSELKUMAB, 1 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1628", "type": "HCPCS"}], "standard_charges": [{"minimum": 67.7, "maximum": 67.7, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 67.7, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ., HAEGARDA 10 UNITS", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J0599", "type": "HCPCS"}], "standard_charges": [{"minimum": 10.78, "maximum": 10.78, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 10.78, "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": 71.38, "maximum": 84.88, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 71.38, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 84.88, "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": 466.19, "maximum": 559.68, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 466.19, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 559.68, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., KANJINTI, 10 MG", "code_information": [{"code": "Q5117", "type": "HCPCS"}], "standard_charges": [{"minimum": 16.91, "maximum": 27.75, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 16.91, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 27.75, "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": 22.37, "maximum": 26.67, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 22.37, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 26.67, "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": 1.99, "maximum": 2.37, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 1.99, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 2.37, "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": 3.59, "maximum": 3.59, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3.59, "methodology": "case rate"}], "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": 94.86, "maximum": 114.19, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 94.86, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 114.19, "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": 11.12, "maximum": 13.27, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 11.12, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 13.27, "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": 3.44, "maximum": 4.08, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3.44, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.08, "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": 212.03, "maximum": 252.7, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 212.03, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 252.7, "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": 28.35, "maximum": 389.2, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 28.35, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 389.2, "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": 75.42, "maximum": 91.42, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 75.42, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 91.42, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., ROLAPITANT, 0.5 MG", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J2797", "type": "HCPCS"}], "standard_charges": [{"minimum": 1.05, "maximum": 1.05, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1.05, "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": 12.98, "maximum": 15.15, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 12.98, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 15.15, "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": 134.09, "maximum": 134.09, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 134.09, "methodology": "case rate"}], "billing_class": "facility"}]}, {"description": "INJ., TRAZIMERA, 10 MG", "code_information": [{"code": "Q5116", "type": "HCPCS"}], "standard_charges": [{"minimum": 12.21, "maximum": 22.37, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 12.21, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 22.37, "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": 7.99, "maximum": 13.01, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 7.99, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 13.01, "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": 10.03, "maximum": 11.79, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 10.03, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 11.79, "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": 3092.37, "maximum": 3676.59, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3092.37, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 3676.59, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., VESTRONIDASE ALFA-VJBK", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3397", "type": "HCPCS"}], "standard_charges": [{"minimum": 261.03, "maximum": 261.03, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 261.03, "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": 504.0, "maximum": 603.13, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 504.0, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 603.13, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ., ZIRABEV, 10 MG", "code_information": [{"code": "Q5118", "type": "HCPCS"}], "standard_charges": [{"minimum": 19.85, "maximum": 27.06, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 19.85, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 27.06, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ.ANESTHETIC AGENT AND/OR STEROID; LUMBAR/SACRAL 64483", "code_information": [{"code": "64483", "type": "CPT"}, {"code": "1481088", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 830.42, "maximum": 3361.0, "gross_charge": 1928.0, "discounted_cash": 1156.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 830.42, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1448.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ.ANESTHETIC AGENT AND/OR STEROID; LUMBAR/SACRAL EA ADD. 64484", "code_information": [{"code": "64484", "type": "CPT"}, {"code": "1583508", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 1590.0, "maximum": 3361.0, "gross_charge": 1928.0, "discounted_cash": 1156.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJ.DIAG./THERA.AGENT PARAVERTEBRAL FACET JOINT W/IMAGE CERVICAL/THORACIC SINGLE LEVEL 64490", "code_information": [{"code": "64490", "type": "CPT"}, {"code": "1481089", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 830.42, "maximum": 3361.0, "gross_charge": 3924.0, "discounted_cash": 2354.4, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 830.42, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1448.71, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECT SINUS TRACT FOR X-RAY", "code_information": [{"code": "20501", "type": "CPT"}], "standard_charges": [{"minimum": 2587.0, "maximum": 5469.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 2587.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 2587.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 5469.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 5196.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 4922.1, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 5469.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 3664.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECT SKIN LESIONS >7", "code_information": [{"code": "11901", "type": "CPT"}], "standard_charges": [{"minimum": 182.4, "maximum": 3361.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 182.4, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", 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"methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 269.84, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 462.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, 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"type": "RC"}], "standard_charges": [{"minimum": 630.04, "maximum": 3361.0, "gross_charge": 1928.0, "discounted_cash": 1156.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 630.04, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1095.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION ANESTHETIC AGENT/STEROID;INTERCOSTAL NERVES MULTIPLE REGIONAL BLOCK 64421", "code_information": [{"code": "64421", "type": "CPT"}, {"code": "1481103", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 830.42, "maximum": 3361.0, "gross_charge": 1928.0, "discounted_cash": 1156.8, "setting": "both", "payers_information": [{"payer_name": 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"standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 630.04, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 1095.38, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION ANESTHETIC AGENT/STEROID;TRIGEMINAL NERVE ANY DIVISION OR BRANCH 64400", "code_information": [{"code": "64400", "type": "CPT"}, {"code": "1481116", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 269.84, "maximum": 3361.0, "gross_charge": 1928.0, "discounted_cash": 1156.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1590.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 3193.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 3024.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 269.84, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 3361.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 2252.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 462.21, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INJECTION ANESTHETIC AGENT;CELIAC PLEXUS 64530", "code_information": [{"code": "64530", "type": "CPT"}, {"code": "1481096", "type": "CDM"}, 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CS/LV LEAD INCL. PPM/ICD 33225", "code_information": [{"code": "33225", "type": "CPT"}, {"code": "45340597", "type": "CDM"}, {"code": "481", "type": "RC"}], "standard_charges": [{"minimum": 2607.0, "maximum": 5511.0, "gross_charge": 29006.0, "discounted_cash": 17403.6, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 2607.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 2607.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 5511.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 5235.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 4959.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 5511.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "INSERT ORACLE LATERAL QUICK INSERTER/DISTRACTOR 03.809.921", "code_information": [{"code": "3.809.921", "type": "CDM"}], "standard_charges": [{"gross_charge": 26250.0, "discounted_cash": 15750.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INSERT PACING ELEC. 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{"description": "INSERT PEDICLE MARKER INSERTER 03.632.058", "code_information": [{"code": "3.632.058", "type": "CDM"}], "standard_charges": [{"gross_charge": 1105.0, "discounted_cash": 663.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INSERT PELV FIXATION DEVICE", "code_information": [{"code": "22848", "type": "CPT"}], "standard_charges": [{"minimum": 5772.0, "maximum": 12203.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 5772.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 5772.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 12203.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 11593.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", 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"both", "billing_class": "facility"}]}, {"description": "MASK ANESTHESIA CHILD/SMALL ADULT SIZE 4 AMCHI4CH", "code_information": [{"code": "AMCHI4CH", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 6.83, "discounted_cash": 4.1, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK ANESTHESIA SM SZ 3 PREMIUM LF PEDI", "code_information": [{"code": "DYNJAAMASK3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 9.42, "discounted_cash": 5.65, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK ANESTHESIA SZ 5 PREMIUM LF ADLT", "code_information": [{"code": "DYNJAAMASK5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 8.81, "discounted_cash": 5.29, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK ANESTHESIA SZ 6 LG NASAL ORAL WITHOUT STRP ADLT DISP", "code_information": [{"code": "1065", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 7.2, "discounted_cash": 4.32, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK ANESTHESIA TODDLER SIZE 3 TODMASK3", "code_information": [{"code": "TODMASK3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 7.28, "discounted_cash": 4.37, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK BASIC PROCEDURE FACE WITH EAR LOOPS NON27378", "code_information": [{"code": "NON27378", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 0.94, "discounted_cash": 0.56, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK BREATHING LG ANESTHESIA PREMIUM SOFT PLUS ADLT", "code_information": [{"code": "5465", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 12.72, "discounted_cash": 7.63, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK COLD COMPRESS SWISS THERAPY REINFORCED", "code_information": [{"code": "IVI1008813", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 51.35, "discounted_cash": 30.81, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK CPAP LARGE HEADGEAR 989805634991", "code_information": [{"code": "9.90E+11", "type": "CDM"}], "standard_charges": [{"gross_charge": 83.64, "discounted_cash": 50.18, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK CPAP LARGE HEADGEAR 989805634991", "code_information": [{"code": "9.90E+11", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 169.62, "discounted_cash": 101.77, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK CPAP LARGE HEADGEAR 989805634991", "code_information": [{"code": "9.90E+11", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 85.0, "discounted_cash": 51.0, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK DUAL ADULT CO2 MONIT MALE LUER 032-10-135U", "code_information": [{"code": "32-10-135U", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 49.14, "discounted_cash": 29.48, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK EYE REINFORCED STERILE SWISS 10-08813", "code_information": [{"code": "10-08813", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 53.13, "discounted_cash": 31.88, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE ANESTHESIA PREMIUM HOOK RING YELLOW ADULT SM", "code_information": [{"code": "5055P1", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 12.22, "discounted_cash": 7.33, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE DISPOSABLE CHILD CLR HOOK RING", "code_information": [{"code": "5448", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 12.84, "discounted_cash": 7.7, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE DISPOSABLE INFANT NO HOOK RING", "code_information": [{"code": "5452", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 12.34, "discounted_cash": 7.4, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE MASK FLUIDSHIELD EAR LOOP", "code_information": [{"code": "41802", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.47, "discounted_cash": 0.28, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE MEDC PROCEDURE YELLOW 80", "code_information": [{"code": "PG4-1001", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.7, "discounted_cash": 0.42, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE REG SURG STRL ADLT DISP", "code_information": [{"code": "7210559", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 194.4, "discounted_cash": 116.64, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE RESPIRATORY MD LG SECURE-GARD N95 LF FLUID RESPIRATOR CONE", "code_information": [{"code": "N95-ML", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2.5, "discounted_cash": 1.5, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE RESPIRATORY SML SECURE-GARD N95 LF FLUID RESPIRATOR CONE", "code_information": [{"code": "N95-S", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 1.78, "discounted_cash": 1.07, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE SZ 3 SOFT CUSHIONINFLATABLE TODDLER ANESTHESIA BREATHING PEDI", "code_information": [{"code": "1032", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 6.84, "discounted_cash": 4.1, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FACE SZ 5 MEDINFLATABLE LF ADLT", "code_information": [{"code": "1055", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 6.3, "discounted_cash": 3.78, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK FLOW SAFE II CPAP LARGE DELUXE STRAIGHT SWIVEL PORT HEAD HARENESS", "code_information": [{"code": "1057209", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 217.8, "discounted_cash": 130.68, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK HIGH-CONCENTRATION NON-REBREATHER 3-IN-1 MASK WITH SAFETY VENT 7' CRUSH-RESISTANT O2 U / CONNEC", "code_information": [{"code": "1268U", "type": "CDM"}], "standard_charges": [{"gross_charge": 8.52, "discounted_cash": 5.11, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARGE ADULT SIZE 6 AMLAD6CH", "code_information": [{"code": "AMLAD6CH", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 19.38, "discounted_cash": 11.63, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL AMBU AURAONCE PVC 15MM MALE CONNECTOR 22.5MM TUBE 40ML CUFF 5", "code_information": [{"code": "321 500 000", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 34.68, "discounted_cash": 20.81, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL AURAONCE LATEX FREE PVC STERILE DISPOSABLE ADULT SIZE 4", "code_information": [{"code": "321 400 000U", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 34.65, "discounted_cash": 20.79, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL SILICONE SIZE 3", "code_information": [{"code": "M0312", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 32.4, "discounted_cash": 19.44, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL SILICONE SIZE 4", "code_information": [{"code": "M0322", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 32.4, "discounted_cash": 19.44, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL SILICONE SIZE 5", "code_information": [{"code": "M0332", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 32.4, "discounted_cash": 19.44, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL SIZE 3", "code_information": [{"code": "ZZZZZ321300000U", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 33.72, "discounted_cash": 20.23, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL SZ 2.5 CHILD LF", "code_information": [{"code": "ALAA025SU", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 32.4, "discounted_cash": 19.44, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LARYNGEAL SZ 2.5 DISPOSABLE LF 321250000U", "code_information": [{"code": "321250000U", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 34.68, "discounted_cash": 20.81, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK LRYNGL AIRWAY LARYSEAL STERILE SZ 4 038-94-240U", "code_information": [{"code": "38-94-240U", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 95.32, "discounted_cash": 57.19, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK MISTY MAX 10IN NEBULIZER", "code_information": [{"code": "2433", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 5.0, "discounted_cash": 3.0, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK NON-REBREATHER VENTURI 7FT TUBE", "code_information": [{"code": "HCS4640", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 6.13, "discounted_cash": 3.68, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK O2 HIGH CONCENTRATION NON REBREATHER THREEIN ONE W/ SAFETY VENTS AND 7FT TU", "code_information": [{"code": "1203", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 5.26, "discounted_cash": 3.16, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK O2 MED CONCENTRATION UNDER CHIN W/ 7FT TUBING LF PEDI", "code_information": [{"code": "1262", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 4.37, "discounted_cash": 2.62, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK O2 OXYMASK ADLT 7 UC", "code_information": [{"code": "OM-1125-8", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 21.6, "discounted_cash": 12.96, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK OXYGEN OXYMASK LATEX FREE VERSAFLEX ENDTIDAL CARBON DIOXIDE ADULT", "code_information": [{"code": "OM-2125-8", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 79.75, "discounted_cash": 47.85, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK OXYGEN PANORAMIC ADULT 301-0318LT", "code_information": [{"code": "301-0318LT", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 48.0, "discounted_cash": 28.8, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PARTICULATE RESPERATOR REG", "code_information": [{"code": "N95A-ML", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2.38, "discounted_cash": 1.43, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PARTICULATE RESPIRATOR SMALL", "code_information": [{"code": "N95A-S", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2.64, "discounted_cash": 1.58, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PED 3 IN 1 SFE VENT", "code_information": [{"code": "1268", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 7.87, "discounted_cash": 4.72, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PEDI DUAL WITH CO2 MONITORING MALE CONNECTOR CAPNOGRAPH", "code_information": [{"code": "329-032-12-143U", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 32.4, "discounted_cash": 19.44, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PINK OVEREAR", "code_information": [{"code": "SDCGCIPKSF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 1.79, "discounted_cash": 1.07, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK POSTOPERATIVE EYE COLD COMPRESS SWISS THERAPY STRL", "code_information": [{"code": "10-08803", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 58.34, "discounted_cash": 35.0, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PREMIUM SMALL ADT RED HOOK RING", "code_information": [{"code": "15055", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 10.49, "discounted_cash": 6.29, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PROC PLEATED EARLOOPS YELLOW 47117", "code_information": [{"code": "47117", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.31, "discounted_cash": 0.19, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PROCEDURE INSTA GARD BLUE W/WRA AT7511-WE", "code_information": [{"code": "AT7511-WE", "type": "CDM"}], "standard_charges": [{"gross_charge": 1.81, "discounted_cash": 1.09, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK PROCEDURE SECURE GARD BLUE AT71021", "code_information": [{"code": "AT71021", "type": "CDM"}], "standard_charges": [{"gross_charge": 0.25, "discounted_cash": 0.15, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK RESP N95 NIOSH APPROVED SMALL 1860S", "code_information": [{"code": "1860S", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2.95, "discounted_cash": 1.77, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK RESPIRONICS BIPAP SMALL 1118937", "code_information": [{"code": "1118937", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 83.64, "discounted_cash": 50.18, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK RESPIRONICS BIPAP LARGE 1061735", "code_information": [{"code": "1061735", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 83.64, "discounted_cash": 50.18, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK RESPIRONICS BIPAP MEDIUM 1061734", "code_information": [{"code": "1061734", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 83.64, "discounted_cash": 50.18, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK RESUSCITATOR BG NASAL ORAL OXYGEN THERAPY W/ 40IN TUBING LF ADLT", "code_information": [{"code": "2K8005", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 55.97, "discounted_cash": 33.58, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK SURG DUCKBILL FOGFREE ANTIGLAR", "code_information": [{"code": "AT54635-I", "type": "CDM"}], "standard_charges": [{"gross_charge": 2.64, "discounted_cash": 1.58, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK SURG SPECIALTY PLEATED SPLASH RESISTANT SENSITIVE SKIN W/ TIES", "code_information": [{"code": "1072835", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.72, "discounted_cash": 0.43, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK TENT W/OXY TUBE", "code_information": [{"code": "1221", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 7.34, "discounted_cash": 4.4, "setting": "both", "billing_class": "facility"}]}, {"description": "MASK TRACHEOSTOMY AIRLIFE ADLT", "code_information": [{"code": "1225", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 5.4, "discounted_cash": 3.24, "setting": "both", "billing_class": "facility"}]}, {"description": "MASSAGE THERAPY", "code_information": [{"code": "97124", "type": "CPT"}], "standard_charges": [{"minimum": 42.86, "maximum": 42.86, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 42.86, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "MAST RAD URBAN TYPE", "code_information": [{"code": "19306", "type": "CPT"}], "standard_charges": [{"minimum": 7568.0, "maximum": 15999.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 7568.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 7568.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 15999.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 15199.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 10719.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 14399.1, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 10719.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 10719.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 15999.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 10719.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "MASTECTOMY FOR GYNECOMASTIA 19300", "code_information": [{"code": "19300", "type": "CPT"}, {"code": "2580862", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 2607.0, "maximum": 5844.26, "gross_charge": 8837.0, "discounted_cash": 5302.2, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 2607.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 2607.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 5511.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 5235.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 4959.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3472.74, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 5511.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 5844.26, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "MASTECTOMY FOR MALIGNANCY WITH CC/MCC", "code_information": [{"code": "582", "type": "MS-DRG"}], "standard_charges": [{"minimum": 11303.59, "maximum": 19625.0, "setting": "inpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 11399.84, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 11399.84, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 18477.34, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 17554.44, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 12380.79, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 16629.61, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 12380.79, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 12380.79, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 11303.59, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 18477.34, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 12380.79, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 19625.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC", "code_information": [{"code": "583", "type": 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"plan_name": "Blue Essentials HMO", "standard_charge_dollar": 5235.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 4959.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 2933.28, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 5511.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 3692.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4836.55, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "ManDiff", "code_information": [{"code": "85007", "type": "CPT"}, {"code": "1099831", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 4.75, "maximum": 47.91, "gross_charge": 105.0, "discounted_cash": 63.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 22.66, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 22.66, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 47.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 32.1, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 43.12, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 32.1, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 32.1, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 47.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 32.1, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 4.75, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Mass spectrometry and tandem mass spectrometry 83789", "code_information": [{"code": "83789", "type": "CPT"}, {"code": "44656955", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 30.14, "maximum": 158.39, "gross_charge": 192.0, "discounted_cash": 115.2, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 74.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 74.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 158.39, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 106.12, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 142.55, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 106.12, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 106.12, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 158.39, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 106.12, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 30.14, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Measurement Of Diameters Of Pelvis In Female", "code_information": [{"code": "74710", "type": "CPT"}], "standard_charges": [{"minimum": 112.42, "maximum": 237.67, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 112.42, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 112.42, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 237.67, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 159.24, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 213.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 159.24, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 159.24, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 237.67, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 159.24, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 173.76, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Medical Device Culture", "code_information": [{"code": "87088", "type": "CPT"}, {"code": "633898", "type": "CDM"}, {"code": "306", "type": "RC"}], "standard_charges": [{"minimum": 10.11, "maximum": 113.27, "gross_charge": 183.0, "discounted_cash": 109.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 53.58, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 53.58, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 113.27, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 75.89, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 101.94, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 75.89, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 75.89, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 113.27, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 75.89, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 10.11, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Medical/Surgical Supplies And Devices Other", "code_information": [{"code": "279", "type": "RC"}], "standard_charges": [{"setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 3300.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 3300.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HMH", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HPN", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}], "billing_class": "facility"}]}, {"description": "Medical/Surgical Supplies And Devices Other Implants", "code_information": [{"code": "278", "type": "RC"}], "standard_charges": [{"setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 3300.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 3300.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HMH", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HPN", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}], "billing_class": "facility"}]}, {"description": "Medical/Surgical Supplies And Devices Pacemaker", "code_information": [{"code": "275", "type": "RC"}], "standard_charges": [{"setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Blue Choice", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HMH", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HPN", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}], "billing_class": "facility"}]}, {"description": "Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices", "code_information": [{"code": "274", "type": "RC"}], "standard_charges": [{"setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 3300.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 3300.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HMH", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "HPN", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "PPO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "additional_payer_notes": "No historical data found for payer/plan and coding combination", "standard_charge_percentage": 70.0, "count": "0", "methodology": "percent of total billed charges"}], "billing_class": "facility"}]}, {"description": "Mercury", "code_information": [{"code": "83825", "type": "CPT"}, {"code": "34555579", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 20.33, "maximum": 121.95, "gross_charge": 394.0, "discounted_cash": 236.4, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 57.68, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 57.68, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 121.95, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 81.71, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 109.76, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 81.71, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 81.71, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 121.95, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 81.71, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 20.33, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Metanephrines 83835", "code_information": [{"code": "83835", "type": "CPT"}, {"code": "44662016", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 21.18, "maximum": 208.91, "gross_charge": 230.0, "discounted_cash": 138.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 98.82, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 98.82, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 208.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 139.97, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 188.02, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 139.97, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 139.97, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 208.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 139.97, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 21.18, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "Methadone 80358", "code_information": [{"code": "80358", "type": "CPT"}, {"code": "44625311", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 5.94, "maximum": 12.55, "gross_charge": 18.0, "discounted_cash": 10.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 5.94, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 5.94, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 12.55, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 8.41, "methodology": "fee schedule"}, 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"discounted_cash": 88.58, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CUSTOM NASAL ENT", "code_information": [{"code": "SEN41ENHGD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 163.81, "discounted_cash": 98.29, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CUSTOM PPM PERIPHERAL DYNJ83533", "code_information": [{"code": "DYNJ83533", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 235.17, "discounted_cash": 141.1, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CUSTOM SHOULDER SCPE", "code_information": [{"code": "SOP41SHHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 187.98, "discounted_cash": 112.79, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CUSTOM SHOULDER SOP41SHHG1", "code_information": [{"code": "SOP41SHHG1", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 376.92, "discounted_cash": 226.15, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CUSTOM SPINE LAMINECTOMY", "code_information": [{"code": "SNE41SPHBC", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 510.59, "discounted_cash": 306.35, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CYSTO SOT41CPHGD", "code_information": [{"code": "SOT41CPHGD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 122.2, "discounted_cash": 73.32, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK CYSTO SOT41CPHGB", "code_information": [{"code": "SOT41CPHGB", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 112.12, "discounted_cash": 67.27, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK ENT NASAL SEN41ENHG7", "code_information": [{"code": "SEN41ENHG7", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 150.12, "discounted_cash": 90.07, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK ENT SEN41ENHG6", "code_information": [{"code": "SEN41ENHG6", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 126.84, "discounted_cash": 76.1, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK ENT SEN41ENHG8", "code_information": [{"code": "SEN41ENHG8", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 149.32, "discounted_cash": 89.59, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK ENT SEN41ENHGG", "code_information": [{"code": "SEN41ENHGG", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 151.32, "discounted_cash": 90.79, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK EYE", "code_information": [{"code": "SEY41CPHPA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 87.72, "discounted_cash": 52.63, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK GYN SMA41PRHG3", "code_information": [{"code": "SMA41PRHG3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 181.98, "discounted_cash": 109.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK GYN SMA41PRHG5", "code_information": [{"code": "SMA41PRHG5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 180.03, "discounted_cash": 108.02, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK GYN SMA41PRHG8", "code_information": [{"code": "SMA41PRHG8", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 198.3, "discounted_cash": 118.98, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HAND & FOOT CUSTOM SOP46HFHG1", "code_information": [{"code": "SOP46HFHG1", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 193.72, "discounted_cash": 116.23, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HAND & FOOT SOP46HFHG4", "code_information": [{"code": "SOP46HFHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 193.12, "discounted_cash": 115.87, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HAND & FOOT SOP46HFHGF", "code_information": [{"code": "SOP46HFHGF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 159.72, "discounted_cash": 95.83, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HAND AND FOOT SOP46HFHG5", "code_information": [{"code": "SOP46HFHG5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 158.76, "discounted_cash": 95.26, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HAND AND FOOT SOP46HFHG3", "code_information": [{"code": "SOP46HFHG3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 193.12, "discounted_cash": 115.87, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HEAD AND NECK 9194", "code_information": [{"code": "9194", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 27.21, "discounted_cash": 16.33, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK HIP TOTAL SOP41THHG7", "code_information": [{"code": "SOP41THHG7", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 291.87, "discounted_cash": 175.12, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK KNEE SOP41TKHG8", "code_information": [{"code": "SOP41TKHG8", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 425.31, "discounted_cash": 255.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK LAVH SMA41LAHG1", "code_information": [{"code": "SMA41LAHG1", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 336.06, "discounted_cash": 201.64, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK LAVH STERILE", "code_information": [{"code": "SLC41LAHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 340.56, "discounted_cash": 204.34, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK MINOR SBA41MNHG5", "code_information": [{"code": "SBA41MNHG5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 146.48, "discounted_cash": 87.89, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK MINOR SBA41MNHG4", "code_information": [{"code": "SBA41MNHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 146.48, "discounted_cash": 87.89, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK MINOR SBA41MNHG6", "code_information": [{"code": "SBA41MNHG6", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 145.88, "discounted_cash": 87.53, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK MINOR SBA41MNHG7", "code_information": [{"code": "SBA41MNHG7", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 145.88, "discounted_cash": 87.53, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK MIS STERILE BUMP", "code_information": [{"code": "57S1MI08", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2224.0, "discounted_cash": 1334.4, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK NOVASURE CO2 CARTRIDGE", "code_information": [{"code": "815012US", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 51.74, "discounted_cash": 31.04, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PACEMAKER STANDARD DYNJS3001", "code_information": [{"code": "DYNJS3001", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 157.58, "discounted_cash": 94.55, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PERI GYN SMA41PRHG2", "code_information": [{"code": "SMA41PRHG2", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 181.53, "discounted_cash": 108.92, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PERI GYN SMA41PRHG4", "code_information": [{"code": "SMA41PRHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 181.53, "discounted_cash": 108.92, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PERI GYN SMA41PRHG6", "code_information": [{"code": "SMA41PRHG6", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 181.35, "discounted_cash": 108.81, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PERI GYN SMA41PRHG7", "code_information": [{"code": "SMA41PRHG7", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 181.35, "discounted_cash": 108.81, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PERI/GYN", "code_information": [{"code": "SMA41PRHGC", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 189.78, "discounted_cash": 113.87, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PREMIUM VACUUM PHACO BL5110", "code_information": [{"code": "BL5110", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 291.9, "discounted_cash": 175.14, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PROCEDURE NAIL FIBULOCK", "code_information": [{"code": "ST6100", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2000.0, "discounted_cash": 1200.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK PROCEDURE STERILE DYNACLIP UNIVERSAL", "code_information": [{"code": "3000-01-000", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 1224.6, "discounted_cash": 734.76, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK RAPID RESPONSE ANGIO K12T-11983", "code_information": [{"code": "K12T-11983", "type": "CDM"}], "standard_charges": [{"gross_charge": 181.5, "discounted_cash": 108.9, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SHOULDER SOP41SHHG2", "code_information": [{"code": "SOP41SHHG2", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 204.45, "discounted_cash": 122.67, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SHOULDER SOP41SHHGG", "code_information": [{"code": "SOP41SHHGG", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 205.41, "discounted_cash": 123.25, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE CUSTOM BAYLOR SHERMAN SNE41SPHG2", "code_information": [{"code": "SNE41SPHG2", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 474.89, "discounted_cash": 284.93, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE CUSTOM BAYLOR SHERMAN SNE41SPHG3", "code_information": [{"code": "SNE41SPHG3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 474.89, "discounted_cash": 284.93, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE CUSTOM BAYLOR SHERMAN SNE41SPHG4", "code_information": [{"code": "SNE41SPHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 474.89, "discounted_cash": 284.93, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE CUSTOM SNE41SPHG5", "code_information": [{"code": "SNE41SPHG5", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 492.86, "discounted_cash": 295.72, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE LAMINECTOMY", "code_information": [{"code": "SNE41SPHGC", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 493.74, "discounted_cash": 296.24, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE LAMINECTOMY SNE41SPHGD", "code_information": [{"code": "SNE41SPHGD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 444.0, "discounted_cash": 266.4, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE SNE41SPHG8", "code_information": [{"code": "SNE41SPHG8", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 427.5, "discounted_cash": 256.5, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SPINE SNE41SPHGE", "code_information": [{"code": "SNE41SPHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 419.82, "discounted_cash": 251.89, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGIAL MINOR HPS1 CUSTOM", "code_information": [{"code": "SMA41MNHGF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 149.2, "discounted_cash": 89.52, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL ABD HYST CARDINAL CUSTOM HSP1", "code_information": [{"code": "SBA41AHHGD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 269.28, "discounted_cash": 161.57, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL ARTHROSCOPY CUSTOM SSH", "code_information": [{"code": "SOP41ARHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 197.52, "discounted_cash": 118.51, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL CATARACT CUSTOM SSH", "code_information": [{"code": "14142-03", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 474.76, "discounted_cash": 284.86, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL CATARACT HP CUSTOM", "code_information": [{"code": "SEY41CPHPD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 95.78, "discounted_cash": 57.47, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL CATARACT HP CUSTOM VER E", "code_information": [{"code": "SEY41CPHPE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 94.2, "discounted_cash": 56.52, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL CATARACT HP CUSTOM VER F", "code_information": [{"code": "SEY41CPHPF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 99.95, "discounted_cash": 59.97, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL DENTAL CARDINAL CUSTOM SHERMAN VER A", "code_information": [{"code": "SEN41DPHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 66.35, "discounted_cash": 39.81, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL ENT SEN41ENHG5", "code_information": [{"code": "SEN41ENHG5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 127.68, "discounted_cash": 76.61, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL EXTREMITY CARDINAL CUSTOM VER 7 PO41EXOK7", "code_information": [{"code": "PO41EXOK7", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 3684.0, "discounted_cash": 2210.4, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL HAND AND FOOT CARDINAL CUSTOM HSP1 VER E", "code_information": [{"code": "SOP46HFHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 195.16, "discounted_cash": 117.1, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL HAND AND FOOT CUSTOM SSH", "code_information": [{"code": "SOP46HFHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 153.12, "discounted_cash": 91.87, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL LAVH CUSTOM SSH", "code_information": [{"code": "SLC41LAHGD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 362.28, "discounted_cash": 217.37, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL MINOR CARDINAL CUSTOM SSH VER G", "code_information": [{"code": "SBA41MNHGG", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 160.92, "discounted_cash": 96.55, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL MINOR CUSTOM SSH", "code_information": [{"code": "SBA41MNHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 159.57, "discounted_cash": 95.74, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL NASAL ENT", "code_information": [{"code": "SEN41ENHG2", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 160.32, "discounted_cash": 96.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL NASAL ENT CARDINAL CUSTOM HSP1 VER 1", "code_information": [{"code": "SEN41ENHG1", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 160.32, "discounted_cash": 96.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL NASAL ENT CARDINAL CUSTOM HSP1 VER E", "code_information": [{"code": "SEN41ENHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 128.84, "discounted_cash": 77.3, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL NASAL ENT SEN41ENHG3", "code_information": [{"code": "SEN41ENHG3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 160.32, "discounted_cash": 96.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL NASEL ENT CARDICAL CUSTOM SEN41ENHGF", "code_information": [{"code": "SEN41ENHGF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 128.84, "discounted_cash": 77.3, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL NASEL ENT CUSTOM SEN41ENHG4", "code_information": [{"code": "SEN41ENHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 128.84, "discounted_cash": 77.3, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL SHOULDER CARDINAL CUSTOM HSP1 VER F", "code_information": [{"code": "SOP41SHHGF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 181.8, "discounted_cash": 109.08, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL SHOULDER CUSTOM SSH", "code_information": [{"code": "SOP41SHHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 191.75, "discounted_cash": 115.05, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL SPINE CUSTOM SSH", "code_information": [{"code": "SNE41SPHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 190.27, "discounted_cash": 114.16, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL TOTAL KNEE CARDINAL CUSTOM MHFC", "code_information": [{"code": "PO41TKHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 780.31, "discounted_cash": 468.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL TOTAL KNEE CARDINAL CUSTOM VER F", "code_information": [{"code": "SOP41TKHGF", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 424.54, "discounted_cash": 254.72, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SURGICAL TOTAL KNEE CUSTOM SSH", "code_information": [{"code": "PO41TKHGA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 706.78, "discounted_cash": 424.07, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SWAB CAP NOVAPLUS XT SWABPACK DISINFECTING CAP VSC-2000", "code_information": [{"code": "VSC-2000", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.56, "discounted_cash": 0.34, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK SYSTEM PROSTEP ORTHOPEDIC FIXATION INTERNAL MIS INSTRUMENT W/ BLADE STERILE DISPOSABLE 57S1MI07", "code_information": [{"code": "57S1MI07", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 798.2, "discounted_cash": 478.92, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TENEX TX PLUS PROCEDURE 1.3IN TIP LENGTH 554-3003-001", "code_information": [{"code": "554-3003-001", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2330.0, "discounted_cash": 1398.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK THREADED TRIMMABLE FIXATION NAIL SIXING GUIDE THN00480", "code_information": [{"code": "THN00480", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 1170.0, "discounted_cash": 702.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOOL DAILY ALIGNMENT VERIFICATION", "code_information": [{"code": "SA-08044", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 15.0, "discounted_cash": 9.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP SOP41THHGE", "code_information": [{"code": "SOP41THHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 378.0, "discounted_cash": 226.8, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP CUSTOM SOP41THHGD", "code_information": [{"code": "SOP41THHGD", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 375.18, "discounted_cash": 225.11, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP HP", "code_information": [{"code": "SOP41THHGB", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 395.78, "discounted_cash": 237.47, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP PACK", "code_information": [{"code": "SOP41THHGC", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 366.45, "discounted_cash": 219.87, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP SOP41THHG4", "code_information": [{"code": "SOP41THHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 376.86, "discounted_cash": 226.12, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP SOP41THHG5", "code_information": [{"code": "SOP41THHG5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 193.24, "discounted_cash": 115.94, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP SOP41THHG6", "code_information": [{"code": "SOP41THHG6", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 240.96, "discounted_cash": 144.58, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL HIP SOP41THHGF", "code_information": [{"code": "SOP41THHGF", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 305.67, "discounted_cash": 183.4, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE CUSTOM SOP41TKHG9", "code_information": [{"code": "SOP41TKHG9", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 425.31, "discounted_cash": 255.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE CUSTOM SOP41TKHGG", "code_information": [{"code": "SOP41TKHGG", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 418.96, "discounted_cash": 251.38, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE HP", "code_information": [{"code": "SOP41TKHGE", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 706.78, "discounted_cash": 424.07, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKH10", "code_information": [{"code": "SOP41TKH10", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 425.31, "discounted_cash": 255.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKH11", "code_information": [{"code": "SOP41TKH11", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 425.31, "discounted_cash": 255.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG1", "code_information": [{"code": "SOP41TKHG1", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 255.81, "discounted_cash": 153.49, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG2", "code_information": [{"code": "SOP41TKHG2", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 260.55, "discounted_cash": 156.33, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG3", "code_information": [{"code": "SOP41TKHG3", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 260.55, "discounted_cash": 156.33, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG4", "code_information": [{"code": "SOP41TKHG4", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 446.84, "discounted_cash": 268.1, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG5", "code_information": [{"code": "SOP41TKHG5", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 389.67, "discounted_cash": 233.8, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG6", "code_information": [{"code": "SOP41TKHG6", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 424.74, "discounted_cash": 254.84, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHG7", "code_information": [{"code": "SOP41TKHG7", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 431.52, "discounted_cash": 258.91, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK TOTAL KNEE SOP41TKHGK", "code_information": [{"code": "SOP41TKHGK", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 431.7, "discounted_cash": 259.02, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK ULTRASOUND 0.9MM TIP FLUID MANAGEMENT SYS ABSINFINITI STRL DISP", "code_information": [{"code": "8065741081", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 195.0, "discounted_cash": 117.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK UNIVERSAL 6 CS 29118", "code_information": [{"code": "29118", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 69.72, "discounted_cash": 41.83, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK UPPER EXTREMITY SPP99EX2AA", "code_information": [{"code": "SPP99EX2AA", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 98.2, "discounted_cash": 58.92, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK VACUUM PHACO", "code_information": [{"code": "BL5111", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 100.0, "discounted_cash": 60.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACK VITRECTOMY ANTINFINITI STRL", "code_information": [{"code": "8065750157", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 360.0, "discounted_cash": 216.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PACKING BLOCK 606.003", "code_information": [{"code": "606.003", "type": "CDM"}], "standard_charges": [{"gross_charge": 1172.6, "discounted_cash": 703.56, "setting": "both", "billing_class": "facility"}]}, {"description": "PACKING BLOCK FOR 26MM DEPTH/ 32MM WIDTH SYNFIXTM-LR 03.802.041", "code_information": [{"code": "3.802.041", "type": "CDM"}], "standard_charges": [{"gross_charge": 4428.0, "discounted_cash": 2656.8, "setting": "both", "billing_class": "facility"}]}, {"description": "PACKING BLOCK FOR 30MM DEPTH/ 38MM WIDTH SYNFIXTM-LR 03.802.042", "code_information": [{"code": "3.802.042", "type": "CDM"}], "standard_charges": [{"gross_charge": 4428.0, "discounted_cash": 2656.8, "setting": "both", "billing_class": "facility"}]}, {"description": "PACKING CURITY 1INX5YD STRIP IODOFORM", "code_information": [{"code": "7833", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 19.44, "discounted_cash": 11.66, "setting": "both", "billing_class": "facility"}]}, {"description": "PACKING TUBE 11-1109-FD8-2", "code_information": [{"code": "11-1109-FD8-2", "type": "CDM"}], "standard_charges": [{"gross_charge": 596.7, "discounted_cash": 358.02, "setting": "both", "billing_class": "facility"}]}, {"description": "PACLITAXEL (AMERICAN REGENT)", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9259", "type": "HCPCS"}], "standard_charges": [{"minimum": 14.48, "maximum": 24.34, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 14.48, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 24.34, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "PACLITAXEL INJECTION", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9267", "type": "HCPCS"}], "standard_charges": [{"minimum": 0.13, "maximum": 0.13, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 0.13, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "PACLITAXEL PROTEIN BOUND", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J9264", "type": "HCPCS"}], "standard_charges": [{"minimum": 13.11, "maximum": 16.85, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 13.11, "methodology": "case rate"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 16.85, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "PAD ABDOMINAL 5IN X 9IN LF STRL", "code_information": [{"code": "NON21450", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.48, "discounted_cash": 0.29, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD ABDOMINAL TENDERSORB 5X9 STERILE 9190A", "code_information": [{"code": "9190A", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 1.06, "discounted_cash": 0.64, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD ADHSV ENT", "code_information": [{"code": "9732500XOM", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 28.56, "discounted_cash": 17.14, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD ARMBOARD 20IN X 8IN X 2IN CONVOLUTED FOAM DEVON LF DISP", "code_information": [{"code": "31143467", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 15.19, "discounted_cash": 9.11, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD ARMBOARD 2IN X 8IN X 20IN CONVOLUTED FOAM WITHOUT COVER LF", "code_information": [{"code": "NON081343", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 6.77, "discounted_cash": 4.06, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD CLEANING ELECTROSURGICAL CAUTERY LATEX FREE SCRATCH STERILE DISPOSABLE", "code_information": [{"code": "ESSP", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 6.87, "discounted_cash": 4.12, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD COMPRESSION 8.5 X 12.25 X .5IN EPI-FOAM FOAM", "code_information": [{"code": "EPF-30", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 98.32, "discounted_cash": 58.99, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD DEFIBRILLATOR HEARTSTART LF ADLT DISP", "code_information": [{"code": "M3713A", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 93.96, "discounted_cash": 56.38, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD EGGCRATE HEEL & ANKLE PAD", "code_information": [{"code": "BI9815", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 24.56, "discounted_cash": 14.74, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD ELECTRODE 4 1/2IN X 6IN ORANGE MONITORING DEFIBRILLATOR UNIVERSAL LF", "code_information": [{"code": "2346N", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 26.71, "discounted_cash": 16.03, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD ELECTRODE 4IN X 3.5IN PED EDGE SYS LF", "code_information": [{"code": "11996-000093", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 178.0, "discounted_cash": 106.8, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD EYE 1 5/8IN X 2 5/8IN LF STRL", "code_information": [{"code": "NON21600Z", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 0.3, "discounted_cash": 0.18, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD EYE 1 5/8IN X 2 5/8IN STRL", "code_information": [{"code": "NON21600", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 0.32, "discounted_cash": 0.19, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING 132 CM2 NON STRL RF LF", "code_information": [{"code": "290-GP", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 36.0, "discounted_cash": 21.6, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING ADULT COND ADH TDS G P 400-2100", "code_information": [{"code": "400-2100", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 13.08, "discounted_cash": 7.85, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING ADULT W/ATTACHED CORD P4500", "code_information": [{"code": "P4500", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 11.64, "discounted_cash": 6.98, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING ELECTRODE NON-REM POLYHESIVE PATIENT RETURN", "code_information": [{"code": "E7506", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 15.07, "discounted_cash": 9.04, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING ESU W/O CABLE 410-2200", "code_information": [{"code": "410-2200", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 35.3, "discounted_cash": 21.18, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING RADIOFREQUENCY DISP", "code_information": [{"code": "RF-DGPS", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 2.4, "discounted_cash": 1.44, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING RF", "code_information": [{"code": "RF-DGP-S", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 42.0, "discounted_cash": 25.2, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD GROUNDING UNIVERSAL SPLIT 9165", "code_information": [{"code": "9165", "type": "CDM"}, {"code": "270", "type": "RC"}], "standard_charges": [{"gross_charge": 22.38, "discounted_cash": 13.43, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD HEEL/ANKLE", "code_information": [{"code": "4815", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 15.58, "discounted_cash": 9.35, "setting": "both", "billing_class": "facility"}]}, {"description": "PAD HOLDER THIGH FOAM DISPOSABLE", "code_information": [{"code": "72201813", "type": "CDM"}, 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ABD. HERNIA RECURRENT INC. MESH 3 CM TO 10 CM 49615", "code_information": [{"code": "49615", "type": "CPT"}, {"code": "46163791", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 3151.98, "maximum": 8726.0, "gross_charge": 8788.0, "discounted_cash": 5272.8, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 4127.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 4127.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 8726.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 8290.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 5846.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 7853.4, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 5846.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 5846.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Medicare Adv HMO", "standard_charge_dollar": 3151.98, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 8726.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 5846.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 6021.28, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REPAIR ANT. 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HOOK WIDE SMALL 134.948", "code_information": [{"code": "134.948", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 OFFSET LAMINA HOOK LEFT 134.922", "code_information": [{"code": "134.922", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 OFFSET LAMINA HOOK RIGHT 134.921", "code_information": [{"code": "134.921", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 PEDICLE HOOK LARGE TRANSVERSE 134.937", "code_information": [{"code": "134.937", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 PEDICLE HOOK LARGE 134.929", "code_information": [{"code": "134.929", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 PEDICLE HOOK MEDIUM TRANSVERSE 134.936", "code_information": [{"code": "134.936", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 PEDICLE HOOK MEDIUM 134.928", "code_information": [{"code": "134.928", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 PEDICLE HOOK SMALL TRANSVERSE 134.935", "code_information": [{"code": "134.935", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 PEDICLE HOOK SMALL 134.927", "code_information": [{"code": "134.927", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 THORACIC LAMINA HOOK MEDIUM 134.905", "code_information": [{"code": "134.905", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 THORACIC LAMINA HOOK NARROW MEDIUM 134.902", "code_information": [{"code": "134.902", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 THORACIC LAMINA HOOK NARROW SMALL 134.901", "code_information": [{"code": "134.901", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 THORACIC LAMINA HOOK SMALL 134.904", "code_information": [{"code": "134.904", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 TRANSVERSE PROCESS HOOK LEFT 134.925", "code_information": [{"code": "134.925", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 6.35 TRANSVERSE PROCESS HOOK RIGHT 134.924", "code_information": [{"code": "134.924", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK EXTRA OFFSET LEFT 1041.9983", "code_information": [{"code": "1041.9983", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK EXTRA OFFSET RIGHT 1041.998", "code_information": [{"code": "1041.998", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK MEDIUM 1041.9945", "code_information": [{"code": "1041.9945", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK NARROW LARGE 1041.9942", "code_information": [{"code": "1041.9942", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK NARROW MEDIUM 1041.9941", "code_information": [{"code": "1041.9941", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK NARROW SMALL 1041.994", "code_information": [{"code": "1041.994", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK SMALL 1041.9944", "code_information": [{"code": "1041.9944", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK UPGOING LARGE 1041.9908", "code_information": [{"code": "1041.9908", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 LAMINA HOOK UPGOING MEDIUM 1041.9907", "code_information": [{"code": "1041.9907", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 PEDICLE HOOK LARGE 1041.9929", "code_information": [{"code": "1041.9929", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 PEDICLE HOOK MEDIUM 1041.9928", "code_information": [{"code": "1041.9928", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 THORACIC LAMINA HOOK MEDIUM 1041.9905", "code_information": [{"code": "1041.9905", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 THORACIC LAMINA HOOK NARROW MEDIUM 1041.9902", "code_information": [{"code": "1041.9902", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE 4.5 THORACIC LAMINA HOOK SMALL 1041.9904", "code_information": [{"code": "1041.9904", "type": "CDM"}], "standard_charges": [{"gross_charge": 1300.0, "discounted_cash": 780.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 15MM 25 and DEG UP 154.532", "code_information": [{"code": "154.532", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 15MM LEFT 25 and DEG UP 154.55", "code_information": [{"code": "154.55", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 15MM LEFT 154.51", "code_information": [{"code": "154.51", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 15MM RIGHT 25 and DEG UP 154.56", "code_information": [{"code": "154.56", "type": "CDM"}], "standard_charges": [{"gross_charge": 1910.0, "discounted_cash": 1146.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 15MM RIGHT 154.52", "code_information": [{"code": "154.52", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 20MM 25 and DEG UP 154.542", "code_information": [{"code": "154.542", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 20MM LEFT 25 and DEG UP 154.552", "code_information": [{"code": "154.552", "type": "CDM"}], "standard_charges": [{"gross_charge": 1910.0, "discounted_cash": 1146.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 20MM LEFT 154.512", "code_information": [{"code": "154.512", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 20MM RIGHT 25 and DEG UP 154.562", "code_information": [{"code": "154.562", "type": "CDM"}], "standard_charges": [{"gross_charge": 1910.0, "discounted_cash": 1146.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP 20MM RIGHT 154.522", "code_information": [{"code": "154.522", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP STRAIGHT 15MM 154.5", "code_information": [{"code": "154.5", "type": "CDM"}], "standard_charges": [{"gross_charge": 1910.0, "discounted_cash": 1146.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERE OFFSET HOUSING CLAMP STRAIGHT 20MM 154.502", "code_information": [{"code": "154.502", "type": "CDM"}], "standard_charges": [{"gross_charge": 1203.8, "discounted_cash": 722.28, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERS SHOULDER CAP PRICE", "code_information": [{"code": "9.80E+11", "type": "CDM"}, {"code": "278", "type": "RC"}], "standard_charges": [{"gross_charge": 18800.0, "discounted_cash": 11280.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERSE CURVED TIP RETRACTOR 12MM X 150MM 687.165", "code_information": [{"code": "687.165", "type": "CDM"}], "standard_charges": [{"gross_charge": 1760.0, "discounted_cash": 1056.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERSE CURVED TIP RETRACTOR 12MM X 200MM 687.166", "code_information": [{"code": "687.166", "type": "CDM"}], "standard_charges": [{"gross_charge": 1760.0, "discounted_cash": 1056.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERSE CURVED TIP RETRACTOR 8MM X 150MM 687.163", "code_information": [{"code": "687.163", "type": "CDM"}], "standard_charges": [{"gross_charge": 1760.0, "discounted_cash": 1056.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVERSE CURVED TIP RETRACTOR 8MM X 200MM 687.164", "code_information": [{"code": "687.164", "type": "CDM"}], "standard_charges": [{"gross_charge": 1760.0, "discounted_cash": 1056.0, "setting": "both", "billing_class": "facility"}]}, {"description": "REVIEW PATIENT SPIROMETRY", "code_information": [{"code": "94016", "type": "CPT"}], "standard_charges": [{"minimum": 35.63, "maximum": 35.63, "setting": "outpatient", "payers_information": [{"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 35.63, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "REVISE & REPAIR CHEST WALL", "code_information": [{"code": "32905", "type": "CPT"}], "standard_charges": 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8.5 MM 8350430", "code_information": [{"code": "8350430", "type": "CDM"}], "standard_charges": [{"gross_charge": 476.42, "discounted_cash": 285.85, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 8350432 OSTEOGRIP THIN 9.5MM 8350432", "code_information": [{"code": "8350432", "type": "CDM"}], "standard_charges": [{"gross_charge": 476.42, "discounted_cash": 285.85, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 8482910 RED MINOR DIA 6.5MM 8482910", "code_information": [{"code": "8482910", "type": "CDM"}], "standard_charges": [{"gross_charge": 1450.0, "discounted_cash": 870.0, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 8482912 RED MINOR DIA 7.5MM 8482912", "code_information": [{"code": "8482912", "type": "CDM"}], "standard_charges": [{"gross_charge": 1450.0, "discounted_cash": 870.0, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 8572030 SOLID TAP 3.75MM COLOR CODED 8572030", 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"TAP 9339017 8.0MM 9339017", "code_information": [{"code": "9339017", "type": "CDM"}], "standard_charges": [{"gross_charge": 1235.52, "discounted_cash": 741.31, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9339019 9.0MM 9339019", "code_information": [{"code": "9339019", "type": "CDM"}], "standard_charges": [{"gross_charge": 1235.52, "discounted_cash": 741.31, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9870060 6.0MM 9870060", "code_information": [{"code": "9870060", "type": "CDM"}], "standard_charges": [{"gross_charge": 1415.7, "discounted_cash": 849.42, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9870065 6.5MM 9870065", "code_information": [{"code": "9870065", "type": "CDM"}], "standard_charges": [{"gross_charge": 1415.7, "discounted_cash": 849.42, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9960045 4.5MM CANNULATED 9960045", "code_information": [{"code": "9960045", "type": "CDM"}], "standard_charges": [{"gross_charge": 1207.44, "discounted_cash": 724.46, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9960055 5.5MM CANNULATED 9960055", "code_information": [{"code": "9960055", "type": "CDM"}], "standard_charges": [{"gross_charge": 1207.44, "discounted_cash": 724.46, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9960065 6.5MM CANNULATED 9960065", "code_information": [{"code": "9960065", "type": "CDM"}], "standard_charges": [{"gross_charge": 1207.44, "discounted_cash": 724.46, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9960070 7.0MM CANNULATED 9960070", "code_information": [{"code": "9960070", "type": "CDM"}], "standard_charges": [{"gross_charge": 1207.44, "discounted_cash": 724.46, "setting": "both", "billing_class": "facility"}]}, {"description": "TAP 9960075 7.5MM CANNULATED 9960075", "code_information": [{"code": "9960075", "type": "CDM"}], "standard_charges": 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"standard_charge_dollar": 12203.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 11593.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 8176.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 10982.7, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 8176.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 8176.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 12203.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 8176.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "TOTAL HIP PACK SOP41THHG8", "code_information": [{"code": 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"BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 6390.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 7101.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "TOTAL HYSTERECTOMY", "code_information": [{"code": "58152", "type": "CPT"}], "standard_charges": [{"minimum": 3259.0, "maximum": 6891.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 3259.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 3259.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 6891.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 6546.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 4617.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 6201.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 4617.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 4617.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 6891.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 4617.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "TOTAL KNEE PACK CUSTOM SOP41TKHGJ", "code_information": [{"code": "SOP41TKHGJ", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 456.66, "discounted_cash": 274.0, "setting": "both", "billing_class": "facility"}]}, {"description": "TOTAL LUNG LAVAGE", "code_information": [{"code": "32997", "type": "CPT"}], "standard_charges": [{"minimum": 3359.0, "maximum": 7101.0, "setting": "outpatient", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 3359.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 3359.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 7101.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 6746.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 6390.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 7101.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "TOTAL SHOULDER REPLACEMENT 23472", "code_information": [{"code": "23472", "type": "CPT"}, {"code": "1482256", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"minimum": 7568.0, "maximum": 22181.74, "gross_charge": 13500.0, "discounted_cash": 8100.0, "setting": "both", "payers_information": 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"standard_charge_dollar": 16978.66, "methodology": "case rate"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 15999.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 10719.0, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 22181.74, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "TOTAL T4", "code_information": [{"code": "84436", "type": "CPT"}, {"code": "1233840", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"minimum": 8.59, "maximum": 91.91, "gross_charge": 50.0, "discounted_cash": 30.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 43.48, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 43.48, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 91.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 61.58, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 82.72, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 61.58, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 61.58, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "PPO", "standard_charge_dollar": 91.91, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Premier HMO", "standard_charge_dollar": 61.58, "methodology": "fee schedule"}, {"payer_name": "HealthChoice", "plan_name": "PPO", "standard_charge_dollar": 8.59, "methodology": "fee schedule"}], "billing_class": "facility"}]}, {"description": "TOTAL THYROID LOBECTOMY WITH CONTRALATERAL SUBTOTAL LOBECTOMY 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"discounted_cash": 8100.0, "setting": "both", "payers_information": [{"payer_name": "BCBS", "plan_name": "BAV", "standard_charge_dollar": 3359.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 3359.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Choice", "standard_charge_dollar": 7101.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Essentials HMO", "standard_charge_dollar": 6746.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "Blue Health", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "City of Dallas PPO", "standard_charge_dollar": 6390.9, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HMH", "standard_charge_dollar": 4758.0, "methodology": "fee schedule"}, {"payer_name": "BCBS", "plan_name": "HPN", "standard_charge_dollar": 4758.0, "methodology": "fee 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"billing_class": "facility"}]}, {"description": "TOURNIQUET COMPRESSION QUICK CONNECT 18IN RED REPROCESSED", "code_information": [{"code": "5921-018-135R", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 60.0, "discounted_cash": 36.0, "setting": "both", "billing_class": "facility"}]}, {"description": "TOURNIQUET COMPRESSION QUICK CONNECT 34IN PURPLE REPROCESSED", "code_information": [{"code": "5921-034-135R", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 52.65, "discounted_cash": 31.59, "setting": "both", "billing_class": "facility"}]}, {"description": "TOURNIQUET CUFF 18 STERILE DISP REPROCESSED", "code_information": [{"code": "60-7070-104R", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 52.65, "discounted_cash": 31.59, "setting": "both", "billing_class": "facility"}]}, {"description": "TOURNIQUET CUFF 18 X 4 IN 1 LINE RED 564006", "code_information": [{"code": "564006", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 87.5, "discounted_cash": 52.5, "setting": "both", "billing_class": "facility"}]}, {"description": "TOURNIQUET CUFF 18IN REPROCESS STRL DISP", "code_information": [{"code": "60-7070-103R", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 52.65, "discounted_cash": 31.59, "setting": "both", "billing_class": "facility"}]}, {"description": "TOURNIQUET CUFF 30 X 4IN 1-LINE WHITE ASP-564010", "code_information": [{"code": "ASP-564010", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 96.52, "discounted_cash": 57.91, "setting": "both", "billing_class": "facility"}]}, {"description": "TOURNIQUET CUFF 34 X 4IN 1-LINE 564012", "code_information": [{"code": "564012", "type": "CDM"}, {"code": "272", "type": "RC"}], "standard_charges": [{"gross_charge": 92.52, "discounted_cash": 55.51, "setting": "both", "billing_class": 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