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in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"}]},{"description":"Hc Ct Lower Ext W/O Contrast Rt","code_information":[{"code":"11663700","type":"CDM"},{"code":"352","type":"RC"},{"code":"73700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1122.0,"discounted_cash":561.0,"setting":"both","modifiers":"RT","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"}]},{"description":"Hc Ct Lower Ext W/Contrast Rt","code_information":[{"code":"11663701","type":"CDM"},{"code":"352","type":"RC"},{"code":"73701","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"discounted_cash":794.0,"setting":"both","modifiers":"RT","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"}]},{"description":"Hc Ct Lower Ext W/Wo Contrast Rt","code_information":[{"code":"11663702","type":"CDM"},{"code":"352","type":"RC"},{"code":"73702","type":"HCPCS"}],"standard_charges":[{"gross_charge":2001.0,"discounted_cash":1000.5,"setting":"both","modifiers":"RT","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"}]},{"description":"Hc Cta-Lower Extremity Right","code_information":[{"code":"11663706","type":"CDM"},{"code":"352","type":"RC"},{"code":"73706","type":"HCPCS"}],"standard_charges":[{"gross_charge":1539.0,"discounted_cash":769.5,"setting":"both","modifiers":"RT","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"}]},{"description":"Hc Splint; Finger L 2 Static-Ot","code_information":[{"code":"11738072","type":"CDM"},{"code":"430","type":"RC"},{"code":"29130","type":"HCPCS"}],"standard_charges":[{"gross_charge":498.0,"discounted_cash":249.0,"setting":"both","modifiers":"GO|F1","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier F1: Left hand, second digit"}]},{"description":"Hc Unna Boot Strapping - 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Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Remove Fb X Au Canal","code_information":[{"code":"92200050","type":"CDM"},{"code":"981","type":"RC"},{"code":"69200","type":"HCPCS"}],"standard_charges":[{"gross_charge":348.0,"discounted_cash":174.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Burn Initial 1St 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is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Noncdm Charge Record Physician","code_information":[{"code":"92227265","type":"CDM"},{"code":"981","type":"RC"},{"code":"27265","type":"HCPCS"}],"standard_charges":[{"gross_charge":2254.0,"discounted_cash":1127.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Cl Tx Tib Shft Fx W Manip","code_information":[{"code":"92227752","type":"CDM"},{"code":"981","type":"RC"},{"code":"27752","type":"HCPCS"}],"standard_charges":[{"gross_charge":2670.0,"discounted_cash":1335.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Cl Tx Distl Fib Fx W Manip","code_information":[{"code":"92227788","type":"CDM"},{"code":"981","type":"RC"},{"code":"27788","type":"HCPCS"}],"standard_charges":[{"gross_charge":2148.0,"discounted_cash":1074.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Cltx Bimalleolar Ankle Fract W Mnp","code_information":[{"code":"92227810","type":"CDM"},{"code":"981","type":"RC"},{"code":"27810","type":"HCPCS"}],"standard_charges":[{"gross_charge":2714.0,"discounted_cash":1357.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Cl Tx Trimall Ankle Fx; W Manip","code_information":[{"code":"92227818","type":"CDM"},{"code":"981","type":"RC"},{"code":"27818","type":"HCPCS"}],"standard_charges":[{"gross_charge":2602.0,"discounted_cash":1301.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Noncdm Charge Record Physician","code_information":[{"code":"92228190","type":"CDM"},{"code":"981","type":"RC"},{"code":"28190","type":"HCPCS"}],"standard_charges":[{"gross_charge":568.0,"discounted_cash":284.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Removal F/B Foot Deep","code_information":[{"code":"92228192","type":"CDM"},{"code":"981","type":"RC"},{"code":"28192","type":"HCPCS"}],"standard_charges":[{"gross_charge":1054.0,"discounted_cash":527.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Closed Tx Fx Phal W/Manip","code_information":[{"code":"92228515","type":"CDM"},{"code":"981","type":"RC"},{"code":"28515","type":"HCPCS"}],"standard_charges":[{"gross_charge":638.0,"discounted_cash":319.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Cl Tx Mtp Jnt Disloc; Wo Anesth","code_information":[{"code":"92228630","type":"CDM"},{"code":"981","type":"RC"},{"code":"28630","type":"HCPCS"}],"standard_charges":[{"gross_charge":344.0,"discounted_cash":172.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Cltx Metatarsophlngl Jt Dislc Req Anes","code_information":[{"code":"92228635","type":"CDM"},{"code":"981","type":"RC"},{"code":"28635","type":"HCPCS"}],"standard_charges":[{"gross_charge":675.0,"discounted_cash":337.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Control Nasal Hemor; Complex","code_information":[{"code":"92230903","type":"CDM"},{"code":"981","type":"RC"},{"code":"30903","type":"HCPCS"}],"standard_charges":[{"gross_charge":647.0,"discounted_cash":323.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Pericardiocentesis","code_information":[{"code":"92233010","type":"CDM"},{"code":"981","type":"RC"},{"code":"33016","type":"HCPCS"}],"standard_charges":[{"gross_charge":778.0,"discounted_cash":389.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Noncdm Charge Record Physician","code_information":[{"code":"92236000","type":"CDM"},{"code":"981","type":"RC"},{"code":"36000","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"discounted_cash":19.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record 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0-2.5","code_information":[{"code":"92241250","type":"CDM"},{"code":"981","type":"RC"},{"code":"41250","type":"HCPCS"}],"standard_charges":[{"gross_charge":477.0,"discounted_cash":238.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Noncdm Charge Record Physician","code_information":[{"code":"92241599","type":"CDM"},{"code":"981","type":"RC"},{"code":"41599","type":"HCPCS"}],"standard_charges":[{"gross_charge":430.0,"discounted_cash":215.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record 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Urethal","code_information":[{"code":"92251702","type":"CDM"},{"code":"981","type":"RC"},{"code":"51702","type":"HCPCS"}],"standard_charges":[{"gross_charge":192.0,"discounted_cash":96.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Penile Injection","code_information":[{"code":"92254235","type":"CDM"},{"code":"981","type":"RC"},{"code":"54235","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"discounted_cash":207.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc I&D Epididymis Tstis&/Scrotal Space","code_information":[{"code":"92254700","type":"CDM"},{"code":"981","type":"RC"},{"code":"54700","type":"HCPCS"}],"standard_charges":[{"gross_charge":624.0,"discounted_cash":312.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Vaginal Delivery Only","code_information":[{"code":"92259409","type":"CDM"},{"code":"981","type":"RC"},{"code":"59409","type":"HCPCS"}],"standard_charges":[{"gross_charge":1931.0,"discounted_cash":965.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Inj Anesth; Trigemin Nrv/Bran","code_information":[{"code":"92264400","type":"CDM"},{"code":"981","type":"RC"},{"code":"64400","type":"HCPCS"}],"standard_charges":[{"gross_charge":661.0,"discounted_cash":330.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Digital Block","code_information":[{"code":"92264450","type":"CDM"},{"code":"981","type":"RC"},{"code":"64450","type":"HCPCS"}],"standard_charges":[{"gross_charge":476.0,"discounted_cash":238.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Removal Corneal Fb W/Slit L","code_information":[{"code":"92265222","type":"CDM"},{"code":"981","type":"RC"},{"code":"65222","type":"HCPCS"}],"standard_charges":[{"gross_charge":307.0,"discounted_cash":153.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Remove Impacted Ear Wax Uni","code_information":[{"code":"92269209","type":"CDM"},{"code":"981","type":"RC"},{"code":"69209","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":38.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Removal Impacted Cerumen W/O A","code_information":[{"code":"92269210","type":"CDM"},{"code":"981","type":"RC"},{"code":"69210","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":42.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Noncdm Charge Record Physician","code_information":[{"code":"92292960","type":"CDM"},{"code":"981","type":"RC"},{"code":"92960","type":"HCPCS"}],"standard_charges":[{"gross_charge":540.0,"discounted_cash":270.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Mod Sed Same Phys/Qhp <5 Yrs Init 15 Min","code_information":[{"code":"92299151","type":"CDM"},{"code":"981","type":"RC"},{"code":"99151","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"discounted_cash":124.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Mod Sed Same Phys/Qhp 5/>Yrs Init 15 Min","code_information":[{"code":"92299152","type":"CDM"},{"code":"981","type":"RC"},{"code":"99152","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"discounted_cash":124.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Mod Sed Same Phys/Qhp Ea Add'l 15 Min","code_information":[{"code":"92299153","type":"CDM"},{"code":"981","type":"RC"},{"code":"99153","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"discounted_cash":124.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Critical Care:Init 30-74 Mins","code_information":[{"code":"92299291","type":"CDM"},{"code":"981","type":"RC"},{"code":"99291","type":"HCPCS"}],"standard_charges":[{"gross_charge":722.0,"discounted_cash":361.0,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Hc Critical Care:Ea Adtnl 30 Min","code_information":[{"code":"92299292","type":"CDM"},{"code":"981","type":"RC"},{"code":"99292","type":"HCPCS"}],"standard_charges":[{"gross_charge":305.0,"discounted_cash":152.5,"setting":"both","modifiers":"AQ","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Plh (151323) | The modified price is presented in the standard charge value. | Modifier AQ: Physician providing a service in an unlisted health professional shortage area (hpsa)"}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"minimum":3698.37,"maximum":3698.37,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care 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The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3698.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Degenerative Nervous System Disorders Without Mcc","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"minimum":20979.0,"maximum":29022.48,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29022.48,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22745.8,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20979.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Cc","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"minimum":13178.96,"maximum":13178.96,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13178.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":11033.42,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3300.91,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11033.42,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8304.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","code_information":[{"code":"065","type":"MS-DRG"}],"standard_charges":[{"minimum":8605.36,"maximum":26583.94,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":26583.94,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8605.36,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8820.77,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Precerebral Occlusion Without Infarction Without Mcc","code_information":[{"code":"068","type":"MS-DRG"}],"standard_charges":[{"minimum":2423.52,"maximum":2423.52,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2423.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Transient Ischemia Without Thrombolytic","code_information":[{"code":"069","type":"MS-DRG"}],"standard_charges":[{"minimum":18648.0,"maximum":20929.23,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20929.23,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18648.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Cerebrovascular Disorders Without Cc/Mcc","code_information":[{"code":"072","type":"MS-DRG"}],"standard_charges":[{"minimum":5468.0,"maximum":5468.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5468.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Traumatic Stupor And Coma <1 Hour With Mcc","code_information":[{"code":"085","type":"MS-DRG"}],"standard_charges":[{"minimum":18644.53,"maximum":18644.53,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18644.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"minimum":13807.83,"maximum":13986.0,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13807.83,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13986.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"minimum":10876.56,"maximum":24214.78,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24214.78,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15077.59,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10876.56,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10936.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"minimum":2341.22,"maximum":22361.2,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22361.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2341.22,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6788.47,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"minimum":4510.49,"maximum":11123.31,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4510.49,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11123.31,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"minimum":2007.20,"maximum":2007.20,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2007.20,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Respiratory System O.R. Procedures With Mcc","code_information":[{"code":"166","type":"MS-DRG"}],"standard_charges":[{"minimum":4574.64,"maximum":4574.64,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4574.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","code_information":[{"code":"175","type":"MS-DRG"}],"standard_charges":[{"minimum":10745.28,"maximum":16126.32,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14461.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10745.28,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16126.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Embolism Without Mcc","code_information":[{"code":"176","type":"MS-DRG"}],"standard_charges":[{"minimum":7625.52,"maximum":18227.24,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18227.24,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7706.14,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7625.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Infections And Inflammations With Mcc","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"minimum":5382.56,"maximum":30326.04,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8469.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13163.57,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11698.76,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5382.56,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10466.55,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17269.18,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7043.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30326.04,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Infections And Inflammations With Cc","code_information":[{"code":"178","type":"MS-DRG"}],"standard_charges":[{"minimum":4118.86,"maximum":7182.46,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5041.12,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7182.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4118.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"minimum":2067.64,"maximum":4839.86,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2067.64,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4839.86,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2639.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"minimum":2685.82,"maximum":2685.82,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2685.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Chest Trauma With Mcc","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"minimum":27972.0,"maximum":27972.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27972.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Edema And Respiratory Failure","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"minimum":2439.0,"maximum":13148.71,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":81.2,"estimated_amount":12932.72,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5028.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11382.55,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13148.71,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4983.46,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10554.59,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2439.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":29391.1,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29391.1,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11819.56,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6308.55,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"minimum":10936.0,"maximum":25128.18,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10936.0,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25128.18,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"minimum":4739.28,"maximum":34442.92,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5038.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34442.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7915.56,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6979.56,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11186.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8032.21,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4739.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"minimum":2691.28,"maximum":20509.14,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5038.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20509.14,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4053.56,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5712.28,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":16128.96,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2691.28,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7272.5,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8685.12,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5161.82,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13240.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"minimum":1704.13,"maximum":12880.37,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12880.37,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6179.25,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1704.13,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6247.17,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5721.1,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4909.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pneumothorax With Mcc","code_information":[{"code":"199","type":"MS-DRG"}],"standard_charges":[{"minimum":5468.0,"maximum":30018.57,"setting":"inpatient","payers_information":[{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30018.57,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5468.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pneumothorax Without Cc/Mcc","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"minimum":12710.94,"maximum":12710.94,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12710.94,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"minimum":8426.05,"maximum":8426.05,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8426.05,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"minimum":8943.66,"maximum":8943.66,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8943.66,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"minimum":2594.14,"maximum":2594.14,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2594.14,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"minimum":2528.4,"maximum":2770.95,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2528.4,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2770.95,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"minimum":2942.0,"maximum":5204.13,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5204.13,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2942.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"minimum":2262.82,"maximum":2262.82,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2262.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute And Subacute Endocarditis With Mcc","code_information":[{"code":"288","type":"MS-DRG"}],"standard_charges":[{"minimum":11402.3,"maximum":11402.3,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11402.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"minimum":5281.08,"maximum":11084.56,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7320.69,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5281.08,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6625.22,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11084.56,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6510.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Heart Failure And Shock With Cc","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"minimum":5876.26,"maximum":5876.26,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5876.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"minimum":8591.83,"maximum":8591.83,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8591.83,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hypertension With Mcc","code_information":[{"code":"304","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":2734.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hypertension Without Mcc","code_information":[{"code":"305","type":"MS-DRG"}],"standard_charges":[{"minimum":2031.9,"maximum":18368.72,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2031.9,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18368.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"minimum":4299.17,"maximum":27537.72,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27537.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10442.88,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4299.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"minimum":2158.9,"maximum":2158.9,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2158.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","code_information":[{"code":"310","type":"MS-DRG"}],"standard_charges":[{"minimum":3430.7,"maximum":11079.18,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11079.18,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3430.7,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5224.18,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Syncope And Collapse","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"minimum":1236.4,"maximum":2734.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1236.4,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Circulatory System Diagnoses With Cc","code_information":[{"code":"315","type":"MS-DRG"}],"standard_charges":[{"minimum":6771.07,"maximum":6771.07,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6771.07,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"minimum":115873.95,"maximum":115873.95,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":115873.95,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Small And Large Bowel Procedures With Cc","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"minimum":11823.2,"maximum":60769.06,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":60769.06,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11823.2,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19410.99,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"minimum":23310.0,"maximum":23310.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23310.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"minimum":11766.93,"maximum":11766.93,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11766.93,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"minimum":14826.35,"maximum":14826.35,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14826.35,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Digestive Malignancy With Mcc","code_information":[{"code":"374","type":"MS-DRG"}],"standard_charges":[{"minimum":11071.98,"maximum":14710.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14710.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11071.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Hemorrhage With Mcc","code_information":[{"code":"377","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":7620.48,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7620.48,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"minimum":1525.64,"maximum":1525.64,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1525.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"minimum":1188.18,"maximum":16477.33,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16477.33,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1188.18,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction With Mcc","code_information":[{"code":"388","type":"MS-DRG"}],"standard_charges":[{"minimum":5468.0,"maximum":10003.84,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10003.84,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5468.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"minimum":7127.82,"maximum":13048.81,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13048.81,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11314.1,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7127.82,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7457.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction Without Cc/Mcc","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"minimum":4922.86,"maximum":14309.4,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14309.4,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11039.44,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4922.86,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7057.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"minimum":16333.17,"maximum":16333.17,"setting":"inpatient","payers_information":[{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16333.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"minimum":6559.44,"maximum":11446.42,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11205.96,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":11446.42,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9036.58,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6559.44,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8325.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System Diagnoses With Cc","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"minimum":2262.82,"maximum":2734.0,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2262.82,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System Diagnoses Without Cc/Mcc","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"minimum":11376.80,"maximum":11376.80,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11376.80,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"minimum":12723.27,"maximum":12723.27,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12723.27,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"minimum":9661.32,"maximum":13864.92,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13864.92,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9661.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Mcc","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"minimum":2768.0,"maximum":2768.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2768.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"minimum":2915.8,"maximum":2915.8,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2915.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"minimum":5568.02,"maximum":14371.37,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14371.37,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":11214.83,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5568.02,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","code_information":[{"code":"441","type":"MS-DRG"}],"standard_charges":[{"minimum":14035.23,"maximum":14035.23,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14035.23,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of The Biliary Tract With Cc","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"minimum":13774.0,"maximum":13774.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13774.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","code_information":[{"code":"482","type":"MS-DRG"}],"standard_charges":[{"minimum":8066.16,"maximum":34497.11,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8066.16,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34497.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Foot Procedures With Cc","code_information":[{"code":"504","type":"MS-DRG"}],"standard_charges":[{"minimum":45502.7,"maximum":45502.7,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":45502.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","code_information":[{"code":"511","type":"MS-DRG"}],"standard_charges":[{"minimum":8682.12,"maximum":8682.12,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8682.12,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fractures Of Femur Without Mcc","code_information":[{"code":"534","type":"MS-DRG"}],"standard_charges":[{"minimum":2719.14,"maximum":2719.14,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2719.14,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"minimum":1575.42,"maximum":1575.42,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1575.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Osteomyelitis With Cc","code_information":[{"code":"540","type":"MS-DRG"}],"standard_charges":[{"minimum":5670.49,"maximum":5670.49,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5670.49,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","code_information":[{"code":"543","type":"MS-DRG"}],"standard_charges":[{"minimum":14415.8,"maximum":14415.8,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14415.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"minimum":20979.0,"maximum":21979.69,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21979.69,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20979.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Tendonitis, Myositis And Bursitis Without Mcc","code_information":[{"code":"558","type":"MS-DRG"}],"standard_charges":[{"minimum":5468.0,"maximum":5468.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5468.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"minimum":23310.0,"maximum":23310.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23310.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"minimum":12843.15,"maximum":23310.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12843.15,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21229.74,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23310.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"561","type":"MS-DRG"}],"standard_charges":[{"minimum":4115.99,"maximum":16317.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11829.28,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4115.99,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16317.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","code_information":[{"code":"564","type":"MS-DRG"}],"standard_charges":[{"minimum":7738.08,"maximum":7738.08,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7738.08,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Skin Ulcers With Cc","code_information":[{"code":"593","type":"MS-DRG"}],"standard_charges":[{"minimum":5426.83,"maximum":5426.83,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5426.83,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cellulitis With Mcc","code_information":[{"code":"602","type":"MS-DRG"}],"standard_charges":[{"minimum":9345.28,"maximum":41536.78,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9345.28,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":41536.78,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"minimum":5278.0,"maximum":30303.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5278.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":9385.31,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5367.58,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10470.23,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7275.2,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30303.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"minimum":7917.0,"maximum":7917.0,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7917.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"minimum":6787.00,"maximum":6787.00,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6787.00,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"minimum":6888.42,"maximum":6888.42,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6888.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes With Cc","code_information":[{"code":"638","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":5633.01,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5633.01,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes Without Cc/Mcc","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":4052.77,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4052.77,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"minimum":8202.0,"maximum":11267.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8469.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8202.0,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11267.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"minimum":1347.34,"maximum":16003.80,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5098.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16003.80,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1347.34,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":9547.32,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7323.85,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2751.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"minimum":19544.0,"maximum":19544.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19544.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"minimum":5468.0,"maximum":5468.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5468.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"minimum":1692.61,"maximum":7878.66,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7878.66,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1692.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"minimum":2808.58,"maximum":29309.96,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":81.2,"estimated_amount":29309.96,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21016.16,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9772.45,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2808.58,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5949.30,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8202.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure Without Cc/Mcc","code_information":[{"code":"684","type":"MS-DRG"}],"standard_charges":[{"minimum":5017.06,"maximum":5017.06,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5017.06,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Neoplasms With Mcc","code_information":[{"code":"686","type":"MS-DRG"}],"standard_charges":[{"minimum":2551.62,"maximum":2551.62,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2551.62,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"minimum":1003.44,"maximum":13387.2,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13387.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4568.76,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1003.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"minimum":1793.59,"maximum":18305.46,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":81.2,"estimated_amount":4043.83,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18305.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8954.51,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6147.02,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5684.46,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1793.59,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10187.11,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14049.56,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Urinary Stones Without Mcc","code_information":[{"code":"694","type":"MS-DRG"}],"standard_charges":[{"minimum":6676.5,"maximum":20437.52,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20437.52,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6676.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Mcc","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"minimum":8202.0,"maximum":8202.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8202.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"minimum":3786.28,"maximum":7738.08,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7738.08,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3786.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammation Of The Male Reproductive System Without Mcc","code_information":[{"code":"728","type":"MS-DRG"}],"standard_charges":[{"minimum":5197.92,"maximum":5197.92,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5197.92,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Malignancy, Female Reproductive System With Cc","code_information":[{"code":"755","type":"MS-DRG"}],"standard_charges":[{"minimum":9553.72,"maximum":9553.72,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9553.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"minimum":9374.4,"maximum":9374.4,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9374.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"809","type":"MS-DRG"}],"standard_charges":[{"minimum":10563.32,"maximum":10563.32,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10563.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Red Blood Cell Disorders With Mcc","code_information":[{"code":"811","type":"MS-DRG"}],"standard_charges":[{"minimum":11008.42,"maximum":18084.58,"setting":"inpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11008.42,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18084.58,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":2734.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"minimum":9311.0,"maximum":9311.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9311.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Reticuloendothelial And Immunity Disorders With Cc","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"minimum":15437.64,"maximum":15437.64,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15437.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","code_information":[{"code":"832","type":"MS-DRG"}],"standard_charges":[{"minimum":3231.45,"maximum":20113.37,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20113.37,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3231.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lymphoma And Non-Acute Leukemia With Mcc","code_information":[{"code":"840","type":"MS-DRG"}],"standard_charges":[{"minimum":5789.86,"maximum":5789.86,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5789.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"minimum":2734.0,"maximum":2734.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2734.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","code_information":[{"code":"853","type":"MS-DRG"}],"standard_charges":[{"minimum":5798.96,"maximum":5798.96,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5798.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fever And Inflammatory Conditions","code_information":[{"code":"864","type":"MS-DRG"}],"standard_charges":[{"minimum":7261.46,"maximum":7261.46,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7261.46,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"minimum":11853.99,"maximum":11853.99,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11853.99,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Cc","code_information":[{"code":"868","type":"MS-DRG"}],"standard_charges":[{"minimum":20984.11,"maximum":20984.11,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20984.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","code_information":[{"code":"871","type":"MS-DRG"}],"standard_charges":[{"minimum":3309.75,"maximum":38083.67,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5278.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32881.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3309.75,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":38083.67,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7381.83,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16534.22,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6894.34,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16253.04,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3903.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","code_information":[{"code":"872","type":"MS-DRG"}],"standard_charges":[{"minimum":2443.0,"maximum":23766.09,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4978.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18758.23,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10020.82,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8826.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":14675.05,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5817.13,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23766.09,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11568.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2443.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"minimum":7016.12,"maximum":13957.78,"setting":"inpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13957.78,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7016.12,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Psychoses","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"minimum":5468.0,"maximum":5468.0,"setting":"inpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5468.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"minimum":1830.6,"maximum":13045.6,"setting":"inpatient","payers_information":[{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1830.6,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13045.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7329.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","code_information":[{"code":"897","type":"MS-DRG"}],"standard_charges":[{"minimum":5576.29,"maximum":16285.72,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16285.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11911.1,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13798.06,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":61.0,"estimated_amount":5576.29,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8006.06,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8006.06,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7227.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Signs And Symptoms With Mcc","code_information":[{"code":"947","type":"MS-DRG"}],"standard_charges":[{"minimum":23985.0,"maximum":24940.83,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24912.09,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24940.83,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23985.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Signs And Symptoms Without Mcc","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"minimum":13706.28,"maximum":25347.11,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17094.67,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13706.28,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25347.11,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23310.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aftercare With Cc/Mcc","code_information":[{"code":"949","type":"MS-DRG"}],"standard_charges":[{"minimum":14958.0,"maximum":48951.0,"setting":"inpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":48951.0,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15375.43,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14958.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Calcitonin salmon injection","code_information":[{"code":"1433","type":"APC"}],"standard_charges":[{"minimum":5475.86,"maximum":7981.07,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7981.07,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":5475.86,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Tetanus immune globulin inj","code_information":[{"code":"1670","type":"APC"}],"standard_charges":[{"minimum":1184.04,"maximum":1184.04,"setting":"outpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1184.04,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Clinic Visits and Related Services","code_information":[{"code":"5012","type":"APC"}],"standard_charges":[{"minimum":16.36,"maximum":461.07,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":16.36,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":163.41,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":58.33,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":55.55,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":461.07,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":50.33,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":163.41,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":159.12,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":124.05,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":58.33,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"minimum":67.84,"maximum":701.32,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":510.05,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":334.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":151.26,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":209.59,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":67.84,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":222.66,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":360.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":510.69,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":169.93,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":112.51,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":349.43,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":149.98,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":363.54,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":236.8,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":509.38,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":701.32,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":197.59,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"minimum":94.84,"maximum":1669.88,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":966.86,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":489.12,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":172.08,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":249.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":334.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":246.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":319.56,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":334.0,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":136.64,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":373.77,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":295.62,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1669.88,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":314.36,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":1201.03,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":206.36,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":321.84,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.5,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":375.18,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":165.42,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":364.25,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":360.98,"methodology":"other"},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":186.90,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":166.48,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":455.95,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":438.60,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":579.08,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":94.84,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":885.88,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":330.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"minimum":55.9,"maximum":2563.53,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2021.12,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":760.54,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1302.72,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":473.72,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":570.32,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":495.34,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":412.63,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":744.79,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":435.49,"methodology":"other"},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":55.9,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":727.05,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":555.31,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":428.88,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1963.67,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1685.55,"methodology":"percent of total billed charges"},{"payer_name":"Encore","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":2563.53,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":617.22,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":295.62,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":666.39,"methodology":"other"},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1264.02,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":411.65,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":447.20,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":472.18,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":363.54,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":494.08,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":443.46,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":2495.65,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1779.18,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":683.40,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":535.52,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1319.24,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1393.25,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2207.07,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":433.14,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":683.39,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":359.07,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"minimum":205.0,"maximum":5619.09,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4455.27,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1708.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3225.2,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":1508.0,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1085.02,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":631.31,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":761.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1819.70,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1179.23,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":2222.28,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1111.89,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":896.15,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":432.28,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":5619.09,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":3048.09,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":280.0,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1434.87,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1629.72,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1637.66,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":822.16,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":720.32,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":784.21,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":782.1,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":932.77,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":205.0,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3542.09,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1330.00,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1045.35,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2850.12,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3017.92,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":376.28,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1761.22,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":964.88,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"minimum":421.05,"maximum":8718.78,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6361.16,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":3107.42,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3109.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":5102.75,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":869.16,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":878.67,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1112.17,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2867.62,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4156.48,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":3847.05,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":512.73,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2178.0,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":8061.03,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":6983.21,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":8718.78,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2669.94,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2334.82,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2791.28,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":421.05,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1096.58,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1070.28,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":931.66,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1082.38,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":8413.92,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6738.16,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1741.08,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6300.14,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2757.99,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2870.67,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1228.30,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"minimum":593.95,"maximum":27167.15,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8862.39,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1603.76,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6303.71,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":4268.07,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1248.24,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":697.88,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1128.83,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2904.17,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3825.33,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":6436.14,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4804.57,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":6141.43,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":954.70,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3616.96,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2634.61,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":593.95,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1265.73,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27167.15,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2283.92,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2423.08,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4316.04,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"minimum":159.71,"maximum":3571.9,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":900.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1927.97,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":304.62,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":449.07,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":768.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":907.05,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":713.07,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":582.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":748.58,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":422.29,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":159.71,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":537.33,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":537.33,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":435.80,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":547.91,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":2811.92,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3571.9,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":580.12,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":612.26,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":789.89,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2083.34,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":693.16,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"minimum":449.07,"maximum":2566.26,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2566.26,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":1098.72,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":622.44,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1284.58,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":604.02,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1710.37,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":980.73,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":449.07,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":487.88,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1166.98,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":806.71,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1096.82,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1252.94,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2019.40,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":452.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"minimum":675.28,"maximum":3444.02,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3444.02,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1282.51,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":675.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Skin Procedures","code_information":[{"code":"5054","type":"APC"}],"standard_charges":[{"minimum":613.34,"maximum":1728.79,"setting":"outpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":613.34,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1728.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"minimum":492.37,"maximum":4584.0,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4584.0,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":507.79,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":492.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"minimum":1279.58,"maximum":26436.01,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4599.85,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4757.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1568.92,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":1708.94,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1279.58,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2822.90,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1771.88,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":26436.01,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1483.22,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1728.79,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4089.14,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1667.80,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3795.9,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1307.89,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"minimum":1395.11,"maximum":16240.88,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14921.22,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1728.79,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":9469.42,"methodology":"percent of total billed charges"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1395.11,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":3507.98,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1451.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16240.88,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3046.27,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"minimum":3184.14,"maximum":13511.42,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3184.14,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":6119.67,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13511.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Strapping and Cast Application","code_information":[{"code":"5101","type":"APC"}],"standard_charges":[{"minimum":419.95,"maximum":1239.78,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1239.78,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":501.44,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":587.07,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":419.95,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":831.26,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Musculoskeletal Procedures","code_information":[{"code":"5111","type":"APC"}],"standard_charges":[{"minimum":832.89,"maximum":6841.93,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1576.6,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1110.21,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":6841.93,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":891.78,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1174.58,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":832.89,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1453.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"minimum":461.42,"maximum":6847.99,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3917.12,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":2918.97,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":5008.39,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1269.90,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6847.99,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1905.42,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":461.42,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1905.42,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1676.56,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1676.56,"methodology":"percent of total billed charges"},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":6666.90,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1554.7,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3672.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"minimum":1817.10,"maximum":30952.05,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30952.05,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18046.54,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":18195.94,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":8439.78,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":3670.26,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5243.51,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2858.13,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1817.10,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":3399.99,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":3399.49,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16749.2,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17288.89,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4804.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"minimum":1905.42,"maximum":43311.27,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35756.28,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":40962.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1905.42,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2526.57,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":14625.12,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8452.22,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15402.62,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13300.53,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3711.95,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3829.94,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2631.04,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":7483.63,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":9895.69,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43311.27,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":33591.10,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14554.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"minimum":4673.47,"maximum":39414.69,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":17872.32,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":39414.69,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":26103.48,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":16980.9,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":26724.63,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4673.47,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17438.10,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":12961.84,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22954.13,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 ENT Procedures","code_information":[{"code":"5161","type":"APC"}],"standard_charges":[{"minimum":594.12,"maximum":594.12,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":594.12,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 ENT Procedures","code_information":[{"code":"5162","type":"APC"}],"standard_charges":[{"minimum":2031.86,"maximum":2031.86,"setting":"outpatient","payers_information":[{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2031.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 ENT Procedures","code_information":[{"code":"5163","type":"APC"}],"standard_charges":[{"minimum":2536.91,"maximum":2536.91,"setting":"outpatient","payers_information":[{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":2536.91,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 1 Vascular Procedures","code_information":[{"code":"5181","type":"APC"}],"standard_charges":[{"minimum":5028.6,"maximum":5028.6,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5028.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"minimum":2780.51,"maximum":13192.63,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":3792.61,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":13192.63,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3252.94,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2780.51,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2993.68,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5024.64,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2903.14,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"minimum":614.09,"maximum":1437.06,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":898.33,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1333.67,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1437.06,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":614.09,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":939.78,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"minimum":735.0,"maximum":4468.22,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1727.75,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3441.7,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":2603.10,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1838.75,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":1217.72,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":2822.14,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1777.02,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1276.02,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":735.0,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4468.22,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3661.96,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1762.40,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"minimum":1916.09,"maximum":6312.46,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5819.01,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1916.09,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5452.55,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6312.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2044.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"minimum":799.0,"maximum":4365.85,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4233.43,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1399.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3896.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":2091.87,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3410.43,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1398.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":1799.45,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":3554.79,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1263.88,"methodology":"other"},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1450.48,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1623.96,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.62,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4365.85,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":857.7,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":799.0,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3177.4,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3687.57,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1255.61,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2553.29,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"minimum":715.77,"maximum":5943.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5701.14,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1576.1,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5943.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":1878.12,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3121.64,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1768.03,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4682.46,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":2456.52,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3902.05,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1775.0,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":4543.84,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1736.19,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2081.06,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3121.64,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3121.64,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":715.77,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3121.64,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5343.57,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1852.77,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":864.0,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3875.30,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5352.10,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1826.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"minimum":2634.95,"maximum":5943.0,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5943.0,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2634.95,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Complex GI Procedures","code_information":[{"code":"5331","type":"APC"}],"standard_charges":[{"minimum":3729.0,"maximum":3729.0,"setting":"outpatient","payers_information":[{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3729.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5341","type":"APC"}],"standard_charges":[{"minimum":2862.0,"maximum":21686.31,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21686.31,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":7347.92,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18571.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":19067.85,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6609.84,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13854.42,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":4297.56,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2862.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20817.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5342","type":"APC"}],"standard_charges":[{"minimum":2486.0,"maximum":15657.48,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15657.48,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13051.74,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2486.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"minimum":2066.62,"maximum":31128.51,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":10645.17,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27207.10,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":11603.16,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2072.12,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2066.62,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":10083.67,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":31128.51,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11844.43,"methodology":"other"},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":14265.36,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16235.78,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3102.81,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3170.45,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4211.34,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4211.34,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":5414.8,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3751.0,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":5414.8,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28495.9,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30800.12,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11755.95,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Laparoscopy and Related Services","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"minimum":9660.06,"maximum":36488.9,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":36488.9,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":9660.06,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17536.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"minimum":385.71,"maximum":539.04,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":539.04,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":385.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Urology and Related Services","code_information":[{"code":"5373","type":"APC"}],"standard_charges":[{"minimum":5825.11,"maximum":5825.11,"setting":"outpatient","payers_information":[{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":5825.11,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Level 4 Urology and Related Services","code_information":[{"code":"5374","type":"APC"}],"standard_charges":[{"minimum":8897.64,"maximum":8897.64,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8897.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Urology and Related Services","code_information":[{"code":"5375","type":"APC"}],"standard_charges":[{"minimum":7624.25,"maximum":7624.25,"setting":"outpatient","payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7624.25,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"minimum":1565.95,"maximum":5943.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5871.24,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5943.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1576.4,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2593.19,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1565.95,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1728.79,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2091.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1872.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"minimum":449.69,"maximum":4122.09,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4122.09,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":449.69,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1339.12,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1242.31,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1326.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"minimum":1518.0,"maximum":5398.97,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4878.39,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1711.64,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":2019.2,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1518.0,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2456.62,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5398.97,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Laser Eye Procedures","code_information":[{"code":"5481","type":"APC"}],"standard_charges":[{"minimum":886.76,"maximum":886.76,"setting":"outpatient","payers_information":[{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":886.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Intraocular Procedures","code_information":[{"code":"5491","type":"APC"}],"standard_charges":[{"minimum":1909.42,"maximum":5943.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2166.58,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5943.0,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2126.9,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1909.42,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2186.91,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5901.72,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2047.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"minimum":63.35,"maximum":1411.9,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.66,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":121.78,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":184.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":152.28,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":80.85,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":68.29,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":80.85,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":109.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":242.27,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":150.26,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":63.35,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":114.68,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":390.95,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":274.95,"methodology":"percent of total billed charges"},{"payer_name":"Encore","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1411.9,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":250.0,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.09,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":102.48,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":126.48,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":68.29,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":66.34,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":95.71,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":65.85,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":68.29,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":296.1,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":173.59,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":85.28,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":85.28,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":173.59,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":323.50,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":169.2,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":115.81,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":101.4,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":332.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"minimum":111.4,"maximum":1251.75,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":525.34,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":186.36,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":258.64,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":317.09,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":258.59,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":216.1,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":255.68,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":192.3,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.51,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":228.53,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":226.56,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":313.7,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":449.75,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":603.72,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":381.48,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":154.27,"methodology":"other"},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":75.0,"estimated_amount":1251.75,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":237.94,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":381.26,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":245.08,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.51,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":232.99,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":280.25,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":653.1,"methodology":"percent of total billed charges"},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":751.1,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":327.66,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":111.4,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":244.28,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":231.58,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":237.61,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":183.24,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":214.59,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":336.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"minimum":158.77,"maximum":1621.2,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1396.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":401.12,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":517.39,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":504.93,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":504.93,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":504.93,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":464.37,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":382.86,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":379.98,"methodology":"other"},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":158.77,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":517.04,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":504.93,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1312.15,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":915.85,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":392.09,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":396.86,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":457.59,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":504.93,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":457.59,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":504.93,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":503.96,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1621.2,"methodology":"percent of total billed charges"},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":998.2,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":487.64,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.23,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":253.22,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":229.95,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":487.64,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":487.64,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":494.04,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":201.42,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":397.44,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1090.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"minimum":487.94,"maximum":4166.07,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2204.54,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":770.96,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2184.83,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":891.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4166.07,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":810.32,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":1072.64,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":2346.4,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1972.26,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":790.89,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":487.94,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1759.8,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2715.12,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":574.39,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2044.72,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2327.80,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":788.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"minimum":44.77,"maximum":2018.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1379.78,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":427.66,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":450.02,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":619.5,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":365.82,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":220.9,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":478.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":479.05,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":507.95,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":693.49,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":389.78,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1500.24,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1121.81,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":2018.0,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":414.61,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":44.77,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":389.78,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":298.78,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1080.82,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":480.79,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":416.37,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":172.42,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":726.89,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":376.79,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":442.88,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":494.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"minimum":374.12,"maximum":1946.22,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1946.22,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":581.41,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":847.77,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":830.79,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1105.85,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.13,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.13,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":632.46,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":646.34,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":694.30,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1859.38,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1368.15,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":578.15,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":627.38,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.13,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":692.36,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.13,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1025.66,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.13,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1663.81,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":830.17,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":374.12,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":858.12,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1231.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":845.31,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":645.47,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":713.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"minimum":233.12,"maximum":2649.48,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":956.51,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2649.48,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":233.12,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1039.82,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":838.23,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":980.06,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":241.22,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1325.69,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1174.87,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2534.19,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":827.65,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1287.26,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":604.09,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2398.68,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":956.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Pathology","code_information":[{"code":"5671","type":"APC"}],"standard_charges":[{"minimum":35.13,"maximum":395.44,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":395.44,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":60.12,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":161.9,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35.13,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35.13,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":302.25,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35.13,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.25,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35.39,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":65.9,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":60.93,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":56.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Pathology","code_information":[{"code":"5673","type":"APC"}],"standard_charges":[{"minimum":294.02,"maximum":3259.17,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1334.04,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":882.87,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1321.86,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":294.02,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":460.25,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1858.75,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3259.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"minimum":2568.71,"maximum":6116.18,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":3872.62,"methodology":"percent of total billed charges"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4801.07,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2568.71,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6116.18,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"minimum":63.64,"maximum":5537.82,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2379.7,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1327.81,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":933.11,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":360.98,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":329.58,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1791.51,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":63.64,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":205.76,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1734.32,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":909.94,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":443.14,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":363.54,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":865.92,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5537.82,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":71.34,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":535.52,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3214.55,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":719.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"minimum":112.64,"maximum":6613.34,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2274.75,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":250.45,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1370.5,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":321.84,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2324.91,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":879.83,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":281.36,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1730.78,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1055.02,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":208.22,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":393.4,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":6613.34,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1530.89,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4736.83,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4833.44,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":820.01,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":773.29,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":398.63,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":112.64,"methodology":"other"},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1386.51,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1572.41,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3572.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1132.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1462.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1378.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"minimum":2736.21,"maximum":8315.05,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2736.21,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4590.74,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4432.82,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6545.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8315.05,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5481.27,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"minimum":100.0,"maximum":1032.5,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":100.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":341.96,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":809.55,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":531.0,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.1,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":348.58,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":466.24,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.1,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1032.5,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":947.05,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":287.44,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":429.58,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.1,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.1,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.1,"methodology":"other"},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1032.5,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":590.09,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":163.9,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":782.64,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":556.1,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":335.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"minimum":141.84,"maximum":2736.72,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":776.96,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":651.92,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1791.48,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":1127.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":720.38,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":972.95,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":2534.22,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":250.0,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":736.98,"methodology":"other"},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":850.04,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":627.79,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.84,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.84,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2736.72,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":294.56,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":710.7,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2018.84,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":726.92,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Minor Procedures","code_information":[{"code":"5731","type":"APC"}],"standard_charges":[{"minimum":153.6,"maximum":781.99,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":153.6,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":781.99,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":354.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"minimum":172.5,"maximum":705.6,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":172.5,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":705.6,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":539.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"minimum":57.4,"maximum":623.61,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":623.61,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":134.4,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":316.59,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":145.45,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":151.68,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":114.08,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":195.62,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":207.71,"methodology":"percent of total billed charges"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":414.4,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":460.2,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":116.47,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":124.83,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.38,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":202.14,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":198.52,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.38,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":181.66,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":319.74,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":57.4,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":62.23,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":194.37,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":322.7,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":142.56,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"minimum":53.38,"maximum":1756.68,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1646.73,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":264.18,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":257.58,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":1028.16,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":176.84,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":338.64,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":189.31,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":1000.96,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":205.6,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":189.36,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1260.0,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":631.15,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":277.9,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":533.08,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":254.65,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":83.84,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":194.75,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":198.55,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":103.98,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":53.38,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":119.88,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1756.68,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":215.16,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":694.27,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":229.36,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Electronic Analysis of Devices","code_information":[{"code":"5742","type":"APC"}],"standard_charges":[{"minimum":90.84,"maximum":1573.02,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":471.84,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1265.8,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":726.38,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":614.32,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":502.83,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":576.34,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":629.12,"methodology":"percent of total billed charges"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1359.4,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":1115.36,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":369.92,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":373.71,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":563.9,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":563.9,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":563.9,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":563.9,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1573.02,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":90.84,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":384.16,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1388.53,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":471.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"minimum":258.16,"maximum":2249.59,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1163.45,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":820.26,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":480.56,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":600.72,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":970.43,"methodology":"percent of total billed charges"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":258.16,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":403.35,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":558.0,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2249.59,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":650.88,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"minimum":32.15,"maximum":2174.29,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1176.8,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":668.58,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":501.91,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":531.01,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":548.92,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":826.39,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":759.02,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":628.84,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":958.86,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":175.42,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":488.88,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":461.19,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":484.72,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":385.82,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2174.29,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":736.14,"methodology":"percent of total billed charges"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1867.44,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32.15,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Health and Behavior Services","code_information":[{"code":"5822","type":"APC"}],"standard_charges":[{"minimum":115.01,"maximum":644.07,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":115.01,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":644.07,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":238.68,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":346.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Health and Behavior Services","code_information":[{"code":"5823","type":"APC"}],"standard_charges":[{"minimum":86.46,"maximum":229.44,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":229.44,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":107.74,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":86.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":101.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Ultrasound Composite","code_information":[{"code":"8004","type":"APC"}],"standard_charges":[{"minimum":711.09,"maximum":861.37,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":861.37,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":711.09,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.49,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.49,"methodology":"other"}],"billing_class":"facility"}]},{"description":"CT and CTA without Contrast Composite","code_information":[{"code":"8005","type":"APC"}],"standard_charges":[{"minimum":441.14,"maximum":5000.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4664.83,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":441.14,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":637.96,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":993.02,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":766.43,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1101.11,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2109.42,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2947.22,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1053.0,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5000.0,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2962.48,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":961.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"CT and CTA with Contrast Composite","code_information":[{"code":"8006","type":"APC"}],"standard_charges":[{"minimum":349.32,"maximum":4177.87,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3860.53,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1565.30,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2091.24,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":4177.26,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1981.85,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1998.21,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1325.91,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1682.06,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":1498.63,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":358.87,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":3673.04,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":3137.82,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2510.54,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2222.21,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2871.91,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1113.25,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":349.32,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2136.4,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1250.46,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4177.87,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1252.44,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1241.99,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1050.08,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1237.7,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1359.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"MRI and MRA without Contrast Composite","code_information":[{"code":"8007","type":"APC"}],"standard_charges":[{"minimum":511.32,"maximum":2900.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2900.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":511.32,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1034.78,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":915.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":921.96,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":915.18,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":851.89,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":915.18,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":904.32,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":772.56,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1134.0,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":915.18,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1701.25,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":915.18,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1396.06,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":514.83,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":625.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":988.08,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":819.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"MRI and MRA with Contrast Composite","code_information":[{"code":"8008","type":"APC"}],"standard_charges":[{"minimum":799.34,"maximum":3635.18,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3635.18,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":799.34,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1695.54,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":1646.39,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1513.24,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1197.44,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":2399.80,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":3055.12,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1300.0,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2872.96,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1860.05,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2135.37,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1485.62,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":895.5,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1689.83,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1510.52,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1170.14,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Comprehensive Observation Services","code_information":[{"code":"8011","type":"APC"}],"standard_charges":[{"minimum":1636.02,"maximum":13083.93,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2771.47,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3593.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":6477.63,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1707.54,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2760.31,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2576.13,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":4574.55,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5213.69,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":3459.38,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2639.83,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3377.39,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":3587.18,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4383.82,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9191.79,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3622.77,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1636.02,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3174.95,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9884.59,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":2568.71,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13083.93,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11184.25,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4576.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Rabies vaccine, im","code_information":[{"code":"9139","type":"APC"}],"standard_charges":[{"minimum":120.47,"maximum":1231.77,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":120.47,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1231.77,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1050.95,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":943.59,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Injection, fulphila","code_information":[{"code":"9173","type":"APC"}],"standard_charges":[{"minimum":1696.74,"maximum":5369.98,"setting":"outpatient","payers_information":[{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":5369.98,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1725.52,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":1696.74,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3160.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Injection, udenyca 0.5 mg","code_information":[{"code":"9195","type":"APC"}],"standard_charges":[{"minimum":2675.66,"maximum":2675.66,"setting":"outpatient","payers_information":[{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2675.66,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inj, remdesivir, 1 mg","code_information":[{"code":"9200","type":"APC"}],"standard_charges":[{"minimum":3502.32,"maximum":3502.32,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3502.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Romiplostim injection","code_information":[{"code":"9245","type":"APC"}],"standard_charges":[{"minimum":5277.39,"maximum":5277.39,"setting":"outpatient","payers_information":[{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5277.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Platelets pheresis path redu","code_information":[{"code":"9536","type":"APC"}],"standard_charges":[{"minimum":958.66,"maximum":1243.86,"setting":"outpatient","payers_information":[{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1243.86,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":958.66,"methodology":"percent of total billed charges"}],"billing_class":"facility"}]},{"description":"Non-OPPS Clinic Services","code_information":[{"code":"N700","type":"APC"}],"standard_charges":[{"minimum":8.53,"maximum":161.2,"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8.53,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":149.8,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":161.2,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":130.2,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":130.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"minimum":10.24,"maximum":527.8,"setting":"outpatient","payers_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":254.1,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":327.23,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":75.12,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":81.28,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":74.3,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":44.86,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":38.01,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43.77,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":106.05,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":38.99,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":124.8,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25.3,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":36.61,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":253.4,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":264.55,"methodology":"percent of total billed charges"},{"payer_name":"First Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":83.0,"estimated_amount":50.0,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43.96,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":72.49,"methodology":"other"},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":89.66,"methodology":"percent of total billed charges"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":124.2,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":50.0,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":33.48,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43.26,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":37.67,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":41.92,"methodology":"other"},{"payer_name":"MediShare","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":307.65,"methodology":"percent of total billed charges"},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10.24,"methodology":"other"},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":371.0,"methodology":"percent of total billed charges"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":75.13,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":36.81,"methodology":"percent of total billed charges"},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":90.5,"estimated_amount":527.8,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":66.75,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":72.76,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":65.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":41.1,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":98.16,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":47.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"minimum":144.97,"maximum":1283.45,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":770.43,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":216.74,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":542.33,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":355.2,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":559.38,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":466.15,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":466.15,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":213.58,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":372.92,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":188.32,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":672.18,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":559.38,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":1283.45,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":854.1,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":186.46,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":275.13,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":397.71,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":559.38,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":559.38,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":279.69,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":745.84,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":466.15,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":369.36,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":144.97,"methodology":"percent of total billed charges"},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":216.5,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":498.54,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1031.04,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":509.36,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":154.12,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":270.96,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":279.69,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"minimum":110.4,"maximum":389.76,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":389.76,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":110.4,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":262.57,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":36.0,"estimated_amount":174.96,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":122.31,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"Caresource","plan_name":"Exchange","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":25.20,"estimated_amount":155.52,"methodology":"percent of total billed charges"},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":70.0,"estimated_amount":255.86,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":312.0,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":327.17,"methodology":"other"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":112.9,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Exchange","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":143.86,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"Physicians Health Plan","plan_name":"HMO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":247.47,"methodology":"other"},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":24.0,"estimated_amount":168.1,"methodology":"percent of total billed charges"},{"payer_name":"Signature Care","plan_name":"EPO","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":247.47,"methodology":"other"},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":247.47,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":265.49,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.46,"methodology":"other"},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":164.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"minimum":8.04,"maximum":487.46,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":33.46,"methodology":"other"},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":207.46,"methodology":"other"},{"payer_name":"Cigna","plan_name":"All Commercial Plans","additional_payer_notes":"No additional payer notes for this estimated amount.","standard_charge_percentage":65.0,"estimated_amount":487.46,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8.04,"methodology":"other"},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":37.28,"methodology":"other"}],"billing_class":"facility"}]}],"modifier_information":[{"description":"Reduced Services","code":"52","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Repeat Clinical Diagnostic Laboratory Test","code":"91","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Distinct Procedural Service","code":"59","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Clia waived test","code":"QW","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Bilateral Procedure","code":"50","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Left side (used to identify procedures performed on the left side of the body)","code":"LT","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Requirements specified in the medical policy have been met","code":"KX","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit","code":"GY","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"NC","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"VD","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Services delivered under an outpatient physical therapy plan of care","code":"GP","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Services delivered under an outpatient occupational therapy plan of care","code":"GO","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Left hand, thumb","code":"FA","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Services delivered under an outpatient speech language pathology plan of care","code":"GN","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Right side (used to identify procedures performed on the right side of the body)","code":"RT","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Preventive Services","code":"33","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Left hand, second digit","code":"F1","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Left hand, third digit","code":"F2","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Physician providing a service in an unlisted health professional shortage area (hpsa)","code":"AQ","modifier_payer_information":[{"payer_name":"Advanced Medical Pricing Solutions (AMPS)","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care - HMO/PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Buckeye Health PLan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Caresource","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Christian Healthcare Ministries","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Encore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Liberty Healthshare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Lucent Health","plan_name":"Coldwater Veneer Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Managed Health Services","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Healthy Indiana Plan Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MDWise","plan_name":"Hoosier Healthwise Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MediShare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Paramount","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Partners Direct Health","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Physicians Health Plan","plan_name":"HMO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"East Central IN Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Group Ministry All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Package Product Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Plain Church","plan_name":"Small Business Aid All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sagamore","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Sana Benefits","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"EPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Signature Care","plan_name":"Exclusive Elite Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Hoosier Care Connect Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care - Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Pathways Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]}]}