{"hospital_name":"Winchester Hospital","last_updated_on":"2026-01-01","version":"2.2.0","hospital_location":["Winchester Hospital"],"hospital_address":["41 Highland Avenue, Winchester, MA 01890"],"license_information":{"license_number":"2094","state":"MA"},"affirmation":{"affirmation":"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.","confirm_affirmation":true},"standard_charge_information":[{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8175-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TICAGRELOR 90 MG TABLET [110427]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0186-0777-39","type":"NDC"}],"standard_charges":[{"gross_charge":21.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1.5 GRAM/300 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [206396]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0124-04","type":"NDC"}],"standard_charges":[{"gross_charge":109.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MANNITOL 20 % INTRAVENOUS SOLUTION [4749]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0357-03","type":"NDC"}],"standard_charges":[{"gross_charge":55.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE IVPB 5 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1055-48","type":"NDC"}],"standard_charges":[{"gross_charge":6.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1559-10","type":"NDC"}],"standard_charges":[{"gross_charge":9.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [106364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1749-29","type":"NDC"}],"standard_charges":[{"gross_charge":16.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9601-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3159-72","type":"NDC"}],"standard_charges":[{"gross_charge":71.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ONDANSETRON HCL 4 MG TABLET [10778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6551-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-705-87","type":"NDC"}],"standard_charges":[{"gross_charge":24.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-174-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TRAZODONE 50 MG TABLET [8085]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-2653-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-047-01","type":"NDC"}],"standard_charges":[{"gross_charge":21.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR 200 MG CAPSULE [8969]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-107-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE [13184]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75834-320-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0018-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0169-1834-11","type":"NDC"}],"standard_charges":[{"gross_charge":13.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9151-30","type":"NDC"}],"standard_charges":[{"gross_charge":9.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-6090-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-1236-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0183-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4277-16","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 500 MG CAPSULE [466]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-2145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7093-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-548-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-209-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINEZOLID 600 MG TABLET [28224]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-309-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 1 MG TABLET [9638]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-555-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-26","type":"NDC"}],"standard_charges":[{"gross_charge":2.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-186-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION [16169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-418-01","type":"NDC"}],"standard_charges":[{"gross_charge":749.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-530-35","type":"NDC"}],"standard_charges":[{"gross_charge":52.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHLORPROMAZINE 25 MG TABLET [1656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1056-1","type":"NDC"}],"standard_charges":[{"gross_charge":2.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEGFILGRASTIM-CBQV (UDENYCA) 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [188896]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70114-101-01","type":"NDC"}],"standard_charges":[{"gross_charge":12086.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BETAXOLOL 0.25 % EYE DROPS,SUSPENSION [19703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0246-10","type":"NDC"}],"standard_charges":[{"gross_charge":864.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM HYDROX-MAGNESIUM CARB 254 MG-237.5 MG/5 ML ORAL SUSPENSION [9018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0088-1173-12","type":"NDC"}],"standard_charges":[{"gross_charge":96.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAPPER [339544]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0116-4005-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1709-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9662-35","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0161-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET [8958]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-2544-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7006-35","type":"NDC"}],"standard_charges":[{"gross_charge":4.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-283-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-145-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DARBEPOETIN ALFA 150 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108046]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-027-01","type":"NDC"}],"standard_charges":[{"gross_charge":1511.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-018-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION [36591]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6193-1","type":"NDC"}],"standard_charges":[{"gross_charge":49.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"60687-662-91","type":"NDC"}],"standard_charges":[{"gross_charge":35.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"TIMOLOL MALEATE 0.5 % EYE DROPS [11562]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64980-514-05","type":"NDC"}],"standard_charges":[{"gross_charge":26.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-153-00","type":"NDC"}],"standard_charges":[{"gross_charge":10.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOBETASOL 0.05 % TOPICAL CREAM [9630]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"69238-1532-5","type":"NDC"}],"standard_charges":[{"gross_charge":12.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 2.5 % EYE DROPS [6246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70756-629-25","type":"NDC"}],"standard_charges":[{"gross_charge":83.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-8660-1","type":"NDC"}],"standard_charges":[{"gross_charge":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-0418-24","type":"NDC"}],"standard_charges":[{"gross_charge":2.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0085-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1055-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1630-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9558-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE GEL [400593]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"35181-7303-32","type":"NDC"}],"standard_charges":[{"gross_charge":93.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORGESTREL 0.3 MG-ETHINYL ESTRADIOL 30 MCG TABLET [10752]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51862-564-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLPHENIDATE 10 MG TABLET [4986]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57664-229-88","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59746-113-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SERTRALINE 25 MG TABLET [19882]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-231-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOTREXATE (ECTOPIC PREGNANCY) IM INJECTION [505009]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-350-37","type":"NDC"}],"standard_charges":[{"gross_charge":13.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-797-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-445-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-553-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2552]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-473-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZTROPINE 1 MG TABLET [999]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-388-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-639-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [178147]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0006-5423-02","type":"NDC"}],"standard_charges":[{"gross_charge":369.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-0400-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-6451-56","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0001-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6729-24","type":"NDC"}],"standard_charges":[{"gross_charge":11.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE HCL 2 MG/250 ML (8 MCG/ML) IN 0.9 % SODIUM CHLOR IV SOLN [132566]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-168-01","type":"NDC"}],"standard_charges":[{"gross_charge":58857.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-240-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBCUTANEOUS SYRINGE [189792]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-998-01","type":"NDC"}],"standard_charges":[{"gross_charge":3755.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZITHROMYCIN 250 MG TABLET [20943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-3060-3","type":"NDC"}],"standard_charges":[{"gross_charge":5.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SERTRALINE 50 MG TABLET [11351]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-242-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-558-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [129339]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-173-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-27","type":"NDC"}],"standard_charges":[{"gross_charge":8.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63402-911-30","type":"NDC"}],"standard_charges":[{"gross_charge":14.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR [9773]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63824-171-63","type":"NDC"}],"standard_charges":[{"gross_charge":18.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306544","type":"NDC"}],"standard_charges":[{"gross_charge":0.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CALCITRIOL 0.25 MCG CAPSULE [9350]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-7352-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER [165233]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0859-14","type":"NDC"}],"standard_charges":[{"gross_charge":434.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10% IN WATER (D10W) IV BOLUS (NEONATAL) [450169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1708-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"IRON SUCROSE IV PUSH WRAPPER (WIN) [339404]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2310-01","type":"NDC"}],"standard_charges":[{"gross_charge":190.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6237-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 125 MG CAPSULE [11628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"23155-858-78","type":"NDC"}],"standard_charges":[{"gross_charge":4.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-132-81","type":"NDC"}],"standard_charges":[{"gross_charge":11.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43825-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51991-144-99","type":"NDC"}],"standard_charges":[{"gross_charge":46.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [176025]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-557-60","type":"NDC"}],"standard_charges":[{"gross_charge":2.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-69","type":"NDC"}],"standard_charges":[{"gross_charge":32.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLUCAGON HCL 1 MG/ML INJECTION WRAPPER [339421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-596-13","type":"NDC"}],"standard_charges":[{"gross_charge":678.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LATANOPROST 0.005 % EYE DROPS [18621]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-421-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [198416]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72485-411-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION [190454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"80830-2363-1","type":"NDC"}],"standard_charges":[{"gross_charge":48.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL-ROPIVACAINE-NACL (PF) 2 MCG/ML-0.1% EPIDURAL SOLUTION [127945]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"9999-9999-47","type":"NDC"}],"standard_charges":[{"gross_charge":104.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-0293-05","type":"NDC"}],"standard_charges":[{"gross_charge":25.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"VANCOMYCIN 125 MG CAPSULE [11628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0121-0867-20","type":"NDC"}],"standard_charges":[{"gross_charge":3.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121119030","type":"NDC"}],"standard_charges":[{"gross_charge":11.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION [172739]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0874-14","type":"NDC"}],"standard_charges":[{"gross_charge":192.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-1800-31","type":"NDC"}],"standard_charges":[{"gross_charge":7.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-5802-10","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":3.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0415-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION WRAPPER [978722]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-31","type":"NDC"}],"standard_charges":[{"gross_charge":10.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0574-4024-35","type":"NDC"}],"standard_charges":[{"gross_charge":9.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-04","type":"NDC"}],"standard_charges":[{"gross_charge":1031.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [121241]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"48433-230-15","type":"NDC"}],"standard_charges":[{"gross_charge":94.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-600-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"AMITRIPTYLINE 25 MG TABLET [435]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-433-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREGABALIN 75 MG CAPSULE [42164]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-495-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELLULOSE, OXIDIZED 4\" X 8\" PADS [632122]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63713-0919-52","type":"NDC"}],"standard_charges":[{"gross_charge":164.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64950-354-05","type":"NDC"}],"standard_charges":[{"gross_charge":8.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZIPRASIDONE 20 MG CAPSULE [29778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-103-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 2.5 MG TABLET [21057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-525-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [82301]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-0775-20","type":"NDC"}],"standard_charges":[{"gross_charge":8.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [128760]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132-0202-20","type":"NDC"}],"standard_charges":[{"gross_charge":4.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOCONAZOLE 2 % TOPICAL CREAM [10368]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0099-15","type":"NDC"}],"standard_charges":[{"gross_charge":19.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1414-48","type":"NDC"}],"standard_charges":[{"gross_charge":28.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1560-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BARIUM SULFATE 40 % (W/V), 29% (W/W) ORAL SUSPENSION [130468]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-121-07","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-301-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAPPER [421040]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-060-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [120086]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-088-01","type":"NDC"}],"standard_charges":[{"gross_charge":11792.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-191-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [29858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-540-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRTAZAPINE 15 MG TABLET [17466]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57664-499-83","type":"NDC"}],"standard_charges":[{"gross_charge":1.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-488-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-182-00","type":"NDC"}],"standard_charges":[{"gross_charge":17.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPYLTHIOURACIL 50 MG TABLET [6662]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-964-95","type":"NDC"}],"standard_charges":[{"gross_charge":5.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1069-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL) [450081]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-0404-41","type":"NDC"}],"standard_charges":[{"gross_charge":2788.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MERCAPTOPURINE 50 MG TABLET [10531]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-4581-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9338-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0574-4024-11","type":"NDC"}],"standard_charges":[{"gross_charge":17.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 20 MG TABLET [3294]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7177-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCHLOROTHIAZIDE 12.5 MG TABLET [76988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-182-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-250-51","type":"NDC"}],"standard_charges":[{"gross_charge":868.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CALCIUM 600 MG (AS CARBONATE)-VITAMIN D3 10 MCG (400 UNIT) TABLET [76978]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026815011","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 20 MG TABLET [3734]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-407-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET [125726]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"54162-017-09","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-221-01","type":"NDC"}],"standard_charges":[{"gross_charge":7570.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WHITE PETROLATUM TOPICAL OINTMENT IN PACKET [132649]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"57896-164-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METHIMAZOLE 5 MG TABLET [10553]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-669-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-736-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-470-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-940-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3475-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEVOTHYROXINE 100 MCG TABLET [4423]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-6624-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 5 MG/ML INJECTION SOLUTION [10608]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2596-05","type":"NDC"}],"standard_charges":[{"gross_charge":16.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0164-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMITRIPTYLINE 25 MG TABLET [435]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-447-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [30070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-541-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [189166]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54288-105-02","type":"NDC"}],"standard_charges":[{"gross_charge":2329.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108043]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-023-01","type":"NDC"}],"standard_charges":[{"gross_charge":604.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ARIPIPRAZOLE 1 MG/ML ORAL SOLUTION [40446]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-0404-5","type":"NDC"}],"standard_charges":[{"gross_charge":319.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMLODIPINE 5 MG TABLET [9071]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-488-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRTAZAPINE 7.5 MG TABLET [38421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-584-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GUANFACINE 1 MG TABLET [10149]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-710-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [168097]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-912-12","type":"NDC"}],"standard_charges":[{"gross_charge":324.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-426-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM-SODIUM PHOSPHATES ORAL SUSPENSION (50 MG/ML ELEMENTARY PHOS) [978496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7135101012","type":"NDC"}],"standard_charges":[{"gross_charge":26.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE(PF) 0.2 %-0.9 % SODCHL 545 ML INFIL,HI VAR RATE ELAST PUMP [188549]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71449-079-51","type":"NDC"}],"standard_charges":[{"gross_charge":990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 75 MG CAPSULE [26546]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72205-044-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"01439-595-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0719-20","type":"NDC"}],"standard_charges":[{"gross_charge":684.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-5535-32","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-41","type":"NDC"}],"standard_charges":[{"gross_charge":4.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SOLUTION [181528]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2552-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS [31025]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-3217-01","type":"NDC"}],"standard_charges":[{"gross_charge":98.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET [76950]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904582460","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-05","type":"NDC"}],"standard_charges":[{"gross_charge":6874.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-132-83","type":"NDC"}],"standard_charges":[{"gross_charge":11.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-192-87","type":"NDC"}],"standard_charges":[{"gross_charge":19.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLESTYRAMINE 4 GRAM ORAL POWDER FOR SUSPENSION IN A PACKET [211218]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42806-270-98","type":"NDC"}],"standard_charges":[{"gross_charge":2.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10%-PRO-IGA 0 TO 50 MCG/ML IV SYR (NEONATAL) [979169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-436-05","type":"NDC"}],"standard_charges":[{"gross_charge":1045.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50268-732-11","type":"NDC"}],"standard_charges":[{"gross_charge":15.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION [1312]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-360-01","type":"NDC"}],"standard_charges":[{"gross_charge":26.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-401-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-198-05","type":"NDC"}],"standard_charges":[{"gross_charge":349.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-436-88","type":"NDC"}],"standard_charges":[{"gross_charge":15.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81033-220-15","type":"NDC"}],"standard_charges":[{"gross_charge":6.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 10 MG TABLET [5005]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-2203-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SYRINGE [123669]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1312-30","type":"NDC"}],"standard_charges":[{"gross_charge":6.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3365-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0436-0672-16","type":"NDC"}],"standard_charges":[{"gross_charge":46.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION [4904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6053-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3540-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-9250-78","type":"NDC"}],"standard_charges":[{"gross_charge":2.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMMONIUM LACTATE 12 % LOTION [10380]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904598426","type":"NDC"}],"standard_charges":[{"gross_charge":9.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-320-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-216-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-448-71","type":"NDC"}],"standard_charges":[{"gross_charge":5.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [120087]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-087-01","type":"NDC"}],"standard_charges":[{"gross_charge":18747.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WARFARIN 1 MG TABLET [11664]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-119-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-447-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-50","type":"NDC"}],"standard_charges":[{"gross_charge":13.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-340-00","type":"NDC"}],"standard_charges":[{"gross_charge":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-477-47","type":"NDC"}],"standard_charges":[{"gross_charge":4.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BETAMETHASONE, AUGMENTED 0.05 % LOTION [9177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0168-0267-30","type":"NDC"}],"standard_charges":[{"gross_charge":126.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS (NEONATAL) [450097]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-03","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1215-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION [6429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6651-19","type":"NDC"}],"standard_charges":[{"gross_charge":8.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5791-46","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904759161","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-420-20","type":"NDC"}],"standard_charges":[{"gross_charge":75.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-305-20","type":"NDC"}],"standard_charges":[{"gross_charge":97.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"45802-410-59","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUMETANIDE 1 MG TABLET [9310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-131-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-120-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-172-30","type":"NDC"}],"standard_charges":[{"gross_charge":9.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-671-40","type":"NDC"}],"standard_charges":[{"gross_charge":4.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET [131038]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6936726701","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [189176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"80830-2362-1","type":"NDC"}],"standard_charges":[{"gross_charge":22.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-0494-20","type":"NDC"}],"standard_charges":[{"gross_charge":33.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-02","type":"NDC"}],"standard_charges":[{"gross_charge":9.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3365-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6625-22","type":"NDC"}],"standard_charges":[{"gross_charge":24.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE 50 MG IRON/2.5 ML INTRAVENOUS SOLUTION [131473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2325-01","type":"NDC"}],"standard_charges":[{"gross_charge":84.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0641-6117-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6449-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYCHLOROQUINE 200 MG TABLET [10235]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7046-06","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOLIC ACID 1 MG TABLET [3233]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7224-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11079]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7077-26","type":"NDC"}],"standard_charges":[{"gross_charge":7.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-EPINEPHRINE HCL 2 MG/250 ML (8 MCG/ML) IN 0.9% SODIUM CHLORIDE (WIN) [505097]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-168-01","type":"NDC"}],"standard_charges":[{"gross_charge":58857.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42494-416-01","type":"NDC"}],"standard_charges":[{"gross_charge":161.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 0.75 % TOPICAL GEL [19741]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-4116-6","type":"NDC"}],"standard_charges":[{"gross_charge":35.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE [189787]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-998-02","type":"NDC"}],"standard_charges":[{"gross_charge":3755.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"AZITHROMYCIN 250 MG TABLET [20943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-742-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-203-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-718-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [169676]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-7669-01","type":"NDC"}],"standard_charges":[{"gross_charge":4284.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INSULIN NPH-REGULAR 70-30 MIX 100 UNIT/ML (U-100) SUBCUTANEOUS SUSP [10286]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8715-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"01439-595-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE 5 % TOPICAL OINTMENT [41831]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0204-37","type":"NDC"}],"standard_charges":[{"gross_charge":68.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 4 MG GUM [10718]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1372-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6044-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOCINOLONE 0.025 % TOPICAL CREAM [3184]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0709-15","type":"NDC"}],"standard_charges":[{"gross_charge":81.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-NOREPINEPHRINE INFUSION 16 MCG/ML IN D5W [440060]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3755-75","type":"NDC"}],"standard_charges":[{"gross_charge":957.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET [9285]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1315-46","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [129971]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-673-77","type":"NDC"}],"standard_charges":[{"gross_charge":14.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-386-62","type":"NDC"}],"standard_charges":[{"gross_charge":41.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-468-13","type":"NDC"}],"standard_charges":[{"gross_charge":25.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"URSODIOL 300 MG CAPSULE [11624]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-796-11","type":"NDC"}],"standard_charges":[{"gross_charge":14.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 20 MG TABLET [11111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-458-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN B COMPLEX AND VITAMIN C NO.20-FOLIC ACID 1 MG CAPSULE [38978]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5852600540","type":"NDC"}],"standard_charges":[{"gross_charge":2.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63020-049-01","type":"NDC"}],"standard_charges":[{"gross_charge":4809.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-03","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733394525","type":"NDC"}],"standard_charges":[{"gross_charge":1.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC99M MERTIATIDE [40840068]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9003-68","type":"NDC"}],"standard_charges":[{"gross_charge":714.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-0221-54","type":"NDC"}],"standard_charges":[{"gross_charge":42.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN IV SYRINGE 5 MG/ML IN D5W (PEDIATRIC) (PREMIX) [632475]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9722-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108130]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4777-23","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-6510-01","type":"NDC"}],"standard_charges":[{"gross_charge":594.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9158-01","type":"NDC"}],"standard_charges":[{"gross_charge":122.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3408-80","type":"NDC"}],"standard_charges":[{"gross_charge":9.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG CAPSULE [10070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5785-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-107-68","type":"NDC"}],"standard_charges":[{"gross_charge":6.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VALSARTAN 40 MG TABLET [33541]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-367-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-241-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VARICELLA-ZOSTER IMMUNE GLOB-MALTOSE 125 UNIT/1.2 ML IM SOLUTION [175403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49591-126-11","type":"NDC"}],"standard_charges":[{"gross_charge":6842.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6148-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-129-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-642-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"61269-730-63","type":"NDC"}],"standard_charges":[{"gross_charge":13.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-172-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFPODOXIME 100 MG TABLET [9468]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-095-20","type":"NDC"}],"standard_charges":[{"gross_charge":5.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION [37642]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65862-596-02","type":"NDC"}],"standard_charges":[{"gross_charge":40.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.15 % EYE DROPS [31158]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"82182-773-05","type":"NDC"}],"standard_charges":[{"gross_charge":297.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [130944]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0011-03","type":"NDC"}],"standard_charges":[{"gross_charge":58.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TETRACAINE HCL (PF) 0.5 % EYE DROPS [131372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0741-14","type":"NDC"}],"standard_charges":[{"gross_charge":36.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0248-01","type":"NDC"}],"standard_charges":[{"gross_charge":29.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3107-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-4827-05","type":"NDC"}],"standard_charges":[{"gross_charge":11.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7510-20","type":"NDC"}],"standard_charges":[{"gross_charge":9.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0552-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLUCAGON HCL 1 MG/ML INJECTION WRAPPER [339421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0548-5850-00","type":"NDC"}],"standard_charges":[{"gross_charge":526.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"BARIUM SULFATE 2.1 % (W/V), 2.0 % (W/W) ORAL SUSPENSION [18299]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-755-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-438-92","type":"NDC"}],"standard_charges":[{"gross_charge":4182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROSUVASTATIN 40 MG TABLET [35136]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-711-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-16","type":"NDC"}],"standard_charges":[{"gross_charge":2.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 2% INJECTION INGREDIENT COMBINED [425001]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-208-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [14983]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-461-01","type":"NDC"}],"standard_charges":[{"gross_charge":43.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68382-860-02","type":"NDC"}],"standard_charges":[{"gross_charge":130.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69918-899-01","type":"NDC"}],"standard_charges":[{"gross_charge":170.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70710-1014-3","type":"NDC"}],"standard_charges":[{"gross_charge":66.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70860-100-41","type":"NDC"}],"standard_charges":[{"gross_charge":8.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 6.25 MG TABLET [15747]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-0135-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0121-0970-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9381-01","type":"NDC"}],"standard_charges":[{"gross_charge":33.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9577-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL 80 MG TABLET [8530]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0343-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-9514-01","type":"NDC"}],"standard_charges":[{"gross_charge":34.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3290-09","type":"NDC"}],"standard_charges":[{"gross_charge":12.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"31722-363-31","type":"NDC"}],"standard_charges":[{"gross_charge":6.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPINIROLE 4 MG TABLET [26429]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-273-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZACITIDINE - SQ USE ONLY [410070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-305-62","type":"NDC"}],"standard_charges":[{"gross_charge":69.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VARENICLINE TARTRATE 0.5 MG TABLET [76444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49884-155-76","type":"NDC"}],"standard_charges":[{"gross_charge":15.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN 2 % TOPICAL OINTMENT [10674]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1312-0","type":"NDC"}],"standard_charges":[{"gross_charge":24.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXCARBAZEPINE 300 MG TABLET [21061]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51991-293-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMAZEPINE 200 MG TABLET [1357]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-444-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-813-01","type":"NDC"}],"standard_charges":[{"gross_charge":26.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROSUVASTATIN 20 MG TABLET [35135]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70377-008-12","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306553","type":"NDC"}],"standard_charges":[{"gross_charge":1.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [196862]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0005-2000-02","type":"NDC"}],"standard_charges":[{"gross_charge":658.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [130004]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-3032-20","type":"NDC"}],"standard_charges":[{"gross_charge":50.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE [168364]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-3023-13","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 500 MG/250 ML (2 MG/ML) IN 0.9% SODIUM CHLORIDE [632281]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9508-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"01439-595-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CEFAZOLIN 2 GRAM/100 ML IN DEXTROSE(ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [175908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3508-41","type":"NDC"}],"standard_charges":[{"gross_charge":27.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [167937]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2308-22","type":"NDC"}],"standard_charges":[{"gross_charge":2.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6022-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 40 MG TABLET [3295]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7178-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7279-66","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-600-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-361-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-795-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-696-02","type":"NDC"}],"standard_charges":[{"gross_charge":34.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLECAINIDE 100 MG TABLET [10041]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-642-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METFORMIN 500 MG TABLET [10544]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-008-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-246-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-0293-05","type":"NDC"}],"standard_charges":[{"gross_charge":25.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LITHIUM CARBONATE 300 MG TABLET [4531]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8528-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE HCL 0.1 MG TABLET [1755]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2127-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERPHENAZINE 2 MG TABLET [6157]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-4101-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0376-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0476-25","type":"NDC"}],"standard_charges":[{"gross_charge":57.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6135-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3451-70","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [78064]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-867-01","type":"NDC"}],"standard_charges":[{"gross_charge":43.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL [28048]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"5140900722","type":"NDC"}],"standard_charges":[{"gross_charge":13.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1370-1","type":"NDC"}],"standard_charges":[{"gross_charge":185.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-4111-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPINIROLE 1 MG TABLET [21689]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-588-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 5 MG TABLET [10451]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-667-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DRONABINOL 2.5 MG CAPSULE [9904]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-753-60","type":"NDC"}],"standard_charges":[{"gross_charge":5.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE 4 MG TABLET [4993]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-149-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER [105699]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"78206-126-02","type":"NDC"}],"standard_charges":[{"gross_charge":166.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE [38321]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-4554-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 40 % ORAL GEL [27466]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0574006915","type":"NDC"}],"standard_charges":[{"gross_charge":7.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-81","type":"NDC"}],"standard_charges":[{"gross_charge":6.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0164-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEVOFLOXACIN 250 MG TABLET [18918]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6351-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-284-25","type":"NDC"}],"standard_charges":[{"gross_charge":4.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-300-01","type":"NDC"}],"standard_charges":[{"gross_charge":176.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE [108027]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55111-679-11","type":"NDC"}],"standard_charges":[{"gross_charge":80.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LOPERAMIDE 2 MG CAPSULE [4560]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-229-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-454-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-665-00","type":"NDC"}],"standard_charges":[{"gross_charge":54.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDODRINE 2.5 MG TABLET [10609]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-240-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-500-41","type":"NDC"}],"standard_charges":[{"gross_charge":7.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3814-50","type":"NDC"}],"standard_charges":[{"gross_charge":36.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6102-19","type":"NDC"}],"standard_charges":[{"gross_charge":8.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION [4904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6053-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [29858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6322-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG TABLET [122410]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42543-098-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-044-06","type":"NDC"}],"standard_charges":[{"gross_charge":12738.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 2,000 UNIT/ML INJECTION SOLUTION [9939]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-126-01","type":"NDC"}],"standard_charges":[{"gross_charge":95.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL 10 MG TABLET [6656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-587-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPHOSPHAMIDE 50 MG CAPSULE [169995]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-619-31","type":"NDC"}],"standard_charges":[{"gross_charge":7.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 125 MG CAPSULE [11628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62559-390-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-398-14","type":"NDC"}],"standard_charges":[{"gross_charge":6.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [39744]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-424-05","type":"NDC"}],"standard_charges":[{"gross_charge":9.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-434-41","type":"NDC"}],"standard_charges":[{"gross_charge":33.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-724-01","type":"NDC"}],"standard_charges":[{"gross_charge":241.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68180-150-01","type":"NDC"}],"standard_charges":[{"gross_charge":95.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-510-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SIMETHICONE 80 MG CHEWABLE TABLET [7227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"77333-812-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-6780-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"},{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [187242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1308-01","type":"NDC"}],"standard_charges":[{"gross_charge":272.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-2223-19","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6057-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BRIMONIDINE 0.1 % EYE DROPS [70262]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-7177-75","type":"NDC"}],"standard_charges":[{"gross_charge":277.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 250 MG (AS CARBONATE)-VITAMIN D3 3.125 MCG (125 UNIT) TABLET [128032]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055502500","type":"NDC"}],"standard_charges":[{"gross_charge":1.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMCICLOVIR 125 MG TABLET [16082]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"33342-024-07","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CITALOPRAM 10 MG/5 ML ORAL SOLUTION [28228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54838-540-70","type":"NDC"}],"standard_charges":[{"gross_charge":401.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54838-566-70","type":"NDC"}],"standard_charges":[{"gross_charge":153.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ABIRATERONE 250 MG TABLET [109776]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-455-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-878-42","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-694-04","type":"NDC"}],"standard_charges":[{"gross_charge":14.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION [191429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-104-50","type":"NDC"}],"standard_charges":[{"gross_charge":7221.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-157-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-583-40","type":"NDC"}],"standard_charges":[{"gross_charge":83.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1643-1","type":"NDC"}],"standard_charges":[{"gross_charge":8.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-146-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0853-20","type":"NDC"}],"standard_charges":[{"gross_charge":35.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-20","type":"NDC"}],"standard_charges":[{"gross_charge":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0089-04","type":"NDC"}],"standard_charges":[{"gross_charge":2.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0553-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4282-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [3738]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0503-06","type":"NDC"}],"standard_charges":[{"gross_charge":3.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3288-91","type":"NDC"}],"standard_charges":[{"gross_charge":3.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG TABLET [26817]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6052-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUSPIRONE 5 MG TABLET [9324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7122-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG DISINTEGRATING TABLET [39713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"41163-449-08","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DESMOPRESSIN 0.1 MG TABLET [16052]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-721-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEXILETINE 150 MG CAPSULE [10595]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-778-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MESALAMINE 4 GRAM/60 ML ENEMA [10535]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62559-420-11","type":"NDC"}],"standard_charges":[{"gross_charge":21.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-401-24","type":"NDC"}],"standard_charges":[{"gross_charge":75.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-710-50","type":"NDC"}],"standard_charges":[{"gross_charge":44.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-PHENYLEPHRINE INFUSION 10 MG/250 ML (40 MCG/ML) IN NS [440061]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-751-00","type":"NDC"}],"standard_charges":[{"gross_charge":862.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE [30961]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-479-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 1.25 MG/ML INJECTION [632141]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-21","type":"NDC"}],"standard_charges":[{"gross_charge":9.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9284-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0007-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9501-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1263-28","type":"NDC"}],"standard_charges":[{"gross_charge":12.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6773-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"THIAMINE (VITAMIN B1) 100 MG TABLET (WRAPPER) [508008]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904719106","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-013-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-627-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"60687-662-91","type":"NDC"}],"standard_charges":[{"gross_charge":34.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-647-25","type":"NDC"}],"standard_charges":[{"gross_charge":105.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-106-15","type":"NDC"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":6.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [168096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-910-12","type":"NDC"}],"standard_charges":[{"gross_charge":202.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WARFARIN 1 MG TABLET [11664]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-761-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-246-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-640-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAZOSIN 1 MG CAPSULE [6468]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-996-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DRONEDARONE 400 MG TABLET [98329]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0024-4142-60","type":"NDC"}],"standard_charges":[{"gross_charge":36.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-4155-73","type":"NDC"}],"standard_charges":[{"gross_charge":3.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1775-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN REGULAR INFUSION SYRINGE 1 UNIT/ML IN NS 25 ML (PEDIATRIC) (PREMIX) [977104]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0126-12","type":"NDC"}],"standard_charges":[{"gross_charge":55.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0241-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7280-80","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOBENZAPRINE 5 MG TABLET [35184]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10702-006-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-295-34","type":"NDC"}],"standard_charges":[{"gross_charge":86.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"17478-824-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":27.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-210-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"AZITHROMYCIN 250 MG TABLET [20943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-074-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [128822]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"58160-820-43","type":"NDC"}],"standard_charges":[{"gross_charge":0.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EZETIMIBE 10 MG TABLET [34153]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-052-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION [6487]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-637-05","type":"NDC"}],"standard_charges":[{"gross_charge":83.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RALOXIFENE 60 MG TABLET [22143]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-709-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC99M SESTAMIBI PER 40 MCI [450049]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9002-13","type":"NDC"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-9018-19","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER [339457]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9380-01","type":"NDC"}],"standard_charges":[{"gross_charge":32.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9430-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-38","type":"NDC"}],"standard_charges":[{"gross_charge":4.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-3390-11","type":"NDC"}],"standard_charges":[{"gross_charge":10.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [121766]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0375-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL 100 MG TABLET [9321]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1064-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXAZOSIN 1 MG TABLET [9894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5522-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-50","type":"NDC"}],"standard_charges":[{"gross_charge":7103.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-345-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE [203880]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-575-00","type":"NDC"}],"standard_charges":[{"gross_charge":6.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-188-10","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [14232]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57237-149-35","type":"NDC"}],"standard_charges":[{"gross_charge":32.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"60687-662-91","type":"NDC"}],"standard_charges":[{"gross_charge":34.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-26","type":"NDC"}],"standard_charges":[{"gross_charge":11.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [169752]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63833-386-02","type":"NDC"}],"standard_charges":[{"gross_charge":3291.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [191775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65597-406-01","type":"NDC"}],"standard_charges":[{"gross_charge":8188.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71839-110-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC99M MEBROFENIN [40840063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9003-67","type":"NDC"}],"standard_charges":[{"gross_charge":100.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-4184-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION [16169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0074-4382-91","type":"NDC"}],"standard_charges":[{"gross_charge":356.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9721-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0258-15","type":"NDC"}],"standard_charges":[{"gross_charge":17.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1559-30","type":"NDC"}],"standard_charges":[{"gross_charge":12.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1761-18","type":"NDC"}],"standard_charges":[{"gross_charge":24.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-12","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17478-404-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-150-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOMETHACIN 25 MG CAPSULE [3897]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-190-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.8 MG/5 ML ORAL SYRUP [121731]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57896-462-08","type":"NDC"}],"standard_charges":[{"gross_charge":64.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEMANTINE 10 MG TABLET [36966]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-184-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-447-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-170-05","type":"NDC"}],"standard_charges":[{"gross_charge":23.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION [31177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65862-535-75","type":"NDC"}],"standard_charges":[{"gross_charge":35.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-855-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 6 MG-MENTHOL 10 MG LOZENGES [41085]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7811201106","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 G OVER 60 / MIN [508207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-500-41","type":"NDC"}],"standard_charges":[{"gross_charge":7.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [190842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4005-24","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9320-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION (PEDS) [978729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-0445-40","type":"NDC"}],"standard_charges":[{"gross_charge":0.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1215-21","type":"NDC"}],"standard_charges":[{"gross_charge":8.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLUCAGON HCL 1 MG/ML INJECTION WRAPPER [339421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0548-5850-00","type":"NDC"}],"standard_charges":[{"gross_charge":526.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION [9938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59676-310-00","type":"NDC"}],"standard_charges":[{"gross_charge":484.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-TRANEXEMIC ACID INFUSION 3,000 MG/250 ML IN NS [975035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61990-0611-2","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-22","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":6.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHENAMINE HIPPURATE 1 GRAM TABLET [10549]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-782-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVONORGESTREL 1.5 MG TABLET [99445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-852-11","type":"NDC"}],"standard_charges":[{"gross_charge":8.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68462-298-17","type":"NDC"}],"standard_charges":[{"gross_charge":28.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72485-422-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 1 MG TABLET [9638]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72888-153-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76204-600-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9873-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0152-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SYRINGE [124908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-31","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7237-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET [121502]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-804-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK [164873]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-826-82","type":"NDC"}],"standard_charges":[{"gross_charge":123.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [78064]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-223-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PYRAZINAMIDE 500 MG TABLET [6738]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"33342-447-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-165-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-349-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLUCOSE CHEWABLE TABLET 4 G (TOT 4 G CHO) [16050]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"56151-1610-51","type":"NDC"}],"standard_charges":[{"gross_charge":0.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [181361]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57894-054-27","type":"NDC"}],"standard_charges":[{"gross_charge":6073.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-27","type":"NDC"}],"standard_charges":[{"gross_charge":14.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-616-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOPIDOGREL 75 MG TABLET [22142]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-536-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-021-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 4 % EYE DROPS [6282]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-201-01","type":"NDC"}],"standard_charges":[{"gross_charge":108.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-3890-1","type":"NDC"}],"standard_charges":[{"gross_charge":2535.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR IRRIGATION, STERILE SOLUTION [7485]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0004-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4276-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED RELEASE [38225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-4117-37","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6007-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-120-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM IODIDE-123 CAPSULE (MILLICURIE) [464102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"48815-1001-1","type":"NDC"}],"standard_charges":[{"gross_charge":399.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-246-58","type":"NDC"}],"standard_charges":[{"gross_charge":868.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BUPROPION HCL 100 MG TABLET [9321]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-143-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEGFILGRASTIM (NEULASTA ONPRO) 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [173927]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-192-01","type":"NDC"}],"standard_charges":[{"gross_charge":11178.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDODRINE 2.5 MG TABLET [10609]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-387-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-405-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-638-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61958-0401-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-285-20","type":"NDC"}],"standard_charges":[{"gross_charge":26.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-904-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-433-82","type":"NDC"}],"standard_charges":[{"gross_charge":6.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [28264]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0088-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 10 MG TABLET [10449]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6798-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-048-35","type":"NDC"}],"standard_charges":[{"gross_charge":38.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-732-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION [189592]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-918-01","type":"NDC"}],"standard_charges":[{"gross_charge":22272.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUMETANIDE 0.5 MG TABLET [9309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-130-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-254-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCITRIOL 0.25 MCG CAPSULE [9350]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-345-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHIMAZOLE 5 MG TABLET [10553]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-669-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62372-630-15","type":"NDC"}],"standard_charges":[{"gross_charge":14.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64950-354-05","type":"NDC"}],"standard_charges":[{"gross_charge":8.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-138-15","type":"NDC"}],"standard_charges":[{"gross_charge":3.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-725-01","type":"NDC"}],"standard_charges":[{"gross_charge":792.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70121-1454-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70436-028-80","type":"NDC"}],"standard_charges":[{"gross_charge":27.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76420-081-01","type":"NDC"}],"standard_charges":[{"gross_charge":234.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81284-611-00","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GENTAMICIN 100 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10112]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0511-41","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DICYCLOMINE 10 MG CAPSULE [2418]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1610-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1560-29","type":"NDC"}],"standard_charges":[{"gross_charge":14.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION (BOLUS) [400745]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3365-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIFEDIPINE 10 MG CAPSULE [5558]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7229-61","type":"NDC"}],"standard_charges":[{"gross_charge":2.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"31722-306-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOCARBAMOL 500 MG TABLET [4971]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-533-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [185012]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-747-03","type":"NDC"}],"standard_charges":[{"gross_charge":13.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"ACEBUTOLOL 200 MG CAPSULE [8939]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-050-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-710-01","type":"NDC"}],"standard_charges":[{"gross_charge":5027.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLUCOSE CHEWABLE TABLET 4 G (TOT 4 G CHO) [16050]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"56151-1612-51","type":"NDC"}],"standard_charges":[{"gross_charge":0.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL 1 MG TABLET [3579]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"58657-901-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OZANIMOD 0.92 MG CAPSULE [193243]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59572-820-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6146-0","type":"NDC"}],"standard_charges":[{"gross_charge":14.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-27","type":"NDC"}],"standard_charges":[{"gross_charge":14.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-152-01","type":"NDC"}],"standard_charges":[{"gross_charge":33.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3302-1","type":"NDC"}],"standard_charges":[{"gross_charge":45.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [130944]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0011-03","type":"NDC"}],"standard_charges":[{"gross_charge":62.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [130005]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-3034-20","type":"NDC"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROCORTISONE 1 % TOPICAL OINTMENT [3731]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0020-31","type":"NDC"}],"standard_charges":[{"gross_charge":17.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4204-52","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-0201-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"METHADONE 10 MG TABLET [4953]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6530-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10019-553-90","type":"NDC"}],"standard_charges":[{"gross_charge":52.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-317-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"3932806412","type":"NDC"}],"standard_charges":[{"gross_charge":31.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION [10442]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-0151-1","type":"NDC"}],"standard_charges":[{"gross_charge":970.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [130348]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"4098522368","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-413-11","type":"NDC"}],"standard_charges":[{"gross_charge":38.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51754-0501-3","type":"NDC"}],"standard_charges":[{"gross_charge":30.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-405-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREGABALIN 100 MG CAPSULE [42165]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-506-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 50 MG/ML INJECTION SOLUTION [4238]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-001-00","type":"NDC"}],"standard_charges":[{"gross_charge":19.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-510-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8770140725","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-9122-16","type":"NDC"}],"standard_charges":[{"gross_charge":31.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION WRAPPER [978722]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-4031-25","type":"NDC"}],"standard_charges":[{"gross_charge":54.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLPIDEM 5 MG TABLET [11701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6082-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-295-12","type":"NDC"}],"standard_charges":[{"gross_charge":127.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-169-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUCRALFATE 1 GRAM TABLET [11442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-695-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE [128173]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6425333335","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROXYCHLOROQUINE 200 MG TABLET [10235]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66993-057-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"67877-124-25","type":"NDC"}],"standard_charges":[{"gross_charge":19.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-246-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MIRTAZAPINE 15 MG TABLET [17466]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-119-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [181238]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69488-001-40","type":"NDC"}],"standard_charges":[{"gross_charge":477.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-371-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NETARSUDIL 0.02 % EYE DROPS [186204]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70727-497-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-118-10","type":"NDC"}],"standard_charges":[{"gross_charge":51.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72205-101-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTASE 9,000 UNIT CHEWABLE TABLET [122812]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8770141251","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-0213-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3073-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POVIDONE-IODINE 5 % EYE SOLUTION [19791]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0411-30","type":"NDC"}],"standard_charges":[{"gross_charge":31.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-16","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [181236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0374-01","type":"NDC"}],"standard_charges":[{"gross_charge":579.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4602-25","type":"NDC"}],"standard_charges":[{"gross_charge":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"VERAPAMIL 120 MG TABLET [8528]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0345-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-3331-19","type":"NDC"}],"standard_charges":[{"gross_charge":3.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 0.3 % EYE DROPS [3428]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-283-10","type":"NDC"}],"standard_charges":[{"gross_charge":9.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 5 % EYE DROPS [7332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-277-15","type":"NDC"}],"standard_charges":[{"gross_charge":55.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 50 MG/ML INJECTION SOLUTION [4238]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-683-10","type":"NDC"}],"standard_charges":[{"gross_charge":26.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 75 MG CAPSULE [26546]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"33342-258-66","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLECAINIDE 100 MG TABLET [10041]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-321-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG TABLET [2405]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-285-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL 0.5 MG TABLET [3578]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-733-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59762-3120-1","type":"NDC"}],"standard_charges":[{"gross_charge":55.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-063-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/50 ML TOPICAL [632522]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0013-1114-21","type":"NDC"}],"standard_charges":[{"gross_charge":12.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-4184-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8175-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1761-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"01439-595-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 40 % ORAL GEL [27466]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0574006905","type":"NDC"}],"standard_charges":[{"gross_charge":5.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-2020-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-165-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":59.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 10 MG/ML INJECTION SOLUTION [4236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-438-01","type":"NDC"}],"standard_charges":[{"gross_charge":42.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-195-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-709-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6808476495","type":"NDC"}],"standard_charges":[{"gross_charge":2.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-157-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BROMOCRIPTINE 2.5 MG TABLET [9297]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-978-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"72485-670-31","type":"NDC"}],"standard_charges":[{"gross_charge":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-99","type":"NDC"}],"standard_charges":[{"gross_charge":1039.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77725]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1576-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10106]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0503-48","type":"NDC"}],"standard_charges":[{"gross_charge":6.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1709-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9159-30","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [165023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9557-12","type":"NDC"}],"standard_charges":[{"gross_charge":63.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [2361]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1775-10","type":"NDC"}],"standard_charges":[{"gross_charge":51.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [174843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0456-2700-01","type":"NDC"}],"standard_charges":[{"gross_charge":1071.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0517-0955-01","type":"NDC"}],"standard_charges":[{"gross_charge":54.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE 20 MG TABLET [10855]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5677-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6305-21","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-253-10","type":"NDC"}],"standard_charges":[{"gross_charge":138.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-400-67","type":"NDC"}],"standard_charges":[{"gross_charge":4.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2552]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62756-797-88","type":"NDC"}],"standard_charges":[{"gross_charge":0.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-445-12","type":"NDC"}],"standard_charges":[{"gross_charge":6.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-434-90","type":"NDC"}],"standard_charges":[{"gross_charge":4.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-435-86","type":"NDC"}],"standard_charges":[{"gross_charge":12.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"71399-0122-4","type":"NDC"}],"standard_charges":[{"gross_charge":7.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-107-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-0418-24","type":"NDC"}],"standard_charges":[{"gross_charge":2.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 100 MG/ML INJECTION SOLUTION [4237]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9509-01","type":"NDC"}],"standard_charges":[{"gross_charge":35.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"INHALATIONAL SPACING DEVICE WITH MEDIUM MASK [187722]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435178810","type":"NDC"}],"standard_charges":[{"gross_charge":13.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TICAGRELOR 60 MG TABLET [176801]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0480-2688-06","type":"NDC"}],"standard_charges":[{"gross_charge":16.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1248-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERPHENAZINE 2 MG TABLET [6157]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6599-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS [5384]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"12547-493-78","type":"NDC"}],"standard_charges":[{"gross_charge":13.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESIPRAMINE 10 MG TABLET [2283]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-112-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATENOLOL 25 MG TABLET [717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-759-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-169-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.15 % EYE DROPS [31158]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-0564-1","type":"NDC"}],"standard_charges":[{"gross_charge":424.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-628-44","type":"NDC"}],"standard_charges":[{"gross_charge":8.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-339-56","type":"NDC"}],"standard_charges":[{"gross_charge":163.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ARIPIPRAZOLE 5 MG TABLET [36438]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-098-31","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINERAL OIL, LIGHT STERILE [191645]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6332325410","type":"NDC"}],"standard_charges":[{"gross_charge":26.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-464-31","type":"NDC"}],"standard_charges":[{"gross_charge":14.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZATHIOPRINE 50 MG TABLET [9183]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-229-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION [10577]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0698-01","type":"NDC"}],"standard_charges":[{"gross_charge":121.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3107-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0116-1061-04","type":"NDC"}],"standard_charges":[{"gross_charge":10.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1610-50","type":"NDC"}],"standard_charges":[{"gross_charge":15.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-17","type":"NDC"}],"standard_charges":[{"gross_charge":10.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION (DRY VIAL) [978603]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-6533-61","type":"NDC"}],"standard_charges":[{"gross_charge":15.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [113082]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0487-5901-99","type":"NDC"}],"standard_charges":[{"gross_charge":4.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION [36591]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4094-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH [117356]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-7313-58","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5854-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EYE DROPS [19746]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-713-10","type":"NDC"}],"standard_charges":[{"gross_charge":46.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-481-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"60687-662-91","type":"NDC"}],"standard_charges":[{"gross_charge":35.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-693-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":5.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68180-722-05","type":"NDC"}],"standard_charges":[{"gross_charge":69.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"72578-089-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 20 MG TABLET [3294]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8297-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 % MUCOSAL SPRAY [27666]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0283-0610-11","type":"NDC"}],"standard_charges":[{"gross_charge":64.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-3029-34","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6013-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METHYLCELLULOSE (WITH SUGAR) 2 GRAM/19 GRAM ORAL POWDER [132008]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904-5675-16","type":"NDC"}],"standard_charges":[{"gross_charge":308.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"10019-120-39","type":"NDC"}],"standard_charges":[{"gross_charge":32.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACOSAMIDE 50 MG TABLET [96968]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-812-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-557-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-155-20","type":"NDC"}],"standard_charges":[{"gross_charge":12.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-198-30","type":"NDC"}],"standard_charges":[{"gross_charge":48.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMAZEPINE 200 MG TABLET [1357]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-0183-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 40 MG TABLET [11112]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-190-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-35","type":"NDC"}],"standard_charges":[{"gross_charge":27.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [78064]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-281-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 325 MG TABLET [681]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-001-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYUREA 500 MG CAPSULE [10236]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-284-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-433-91","type":"NDC"}],"standard_charges":[{"gross_charge":6.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-LIDOCAINE 1% PF-BUPIVACAINE 0.25% PF 50/50 MIX [632205]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4002-64","type":"NDC"}],"standard_charges":[{"gross_charge":3.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"APIXABAN 5 MG TABLET [119614]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-0894-31","type":"NDC"}],"standard_charges":[{"gross_charge":20.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9320-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7391-82","type":"NDC"}],"standard_charges":[{"gross_charge":41.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER [41142]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0597-0087-17","type":"NDC"}],"standard_charges":[{"gross_charge":1009.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 10 MG/ML INJECTION SOLUTION (WRAPPER) [975234]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6127-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOBETASOL 0.05 % TOPICAL OINTMENT [9631]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0656-15","type":"NDC"}],"standard_charges":[{"gross_charge":10.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 20 MG TABLET [11111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5892-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION [123492]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-503-05","type":"NDC"}],"standard_charges":[{"gross_charge":750.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"21922-029-04","type":"NDC"}],"standard_charges":[{"gross_charge":69.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-170-31","type":"NDC"}],"standard_charges":[{"gross_charge":24.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY [126676]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5093009802","type":"NDC"}],"standard_charges":[{"gross_charge":17.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-127-15","type":"NDC"}],"standard_charges":[{"gross_charge":11.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-481-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62756-071-60","type":"NDC"}],"standard_charges":[{"gross_charge":34.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-229-94","type":"NDC"}],"standard_charges":[{"gross_charge":23.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35942]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66758-170-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROMETHAZINE 25 MG TABLET [6622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-155-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-063-59","type":"NDC"}],"standard_charges":[{"gross_charge":12.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [9774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-149-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9318-10","type":"NDC"}],"standard_charges":[{"gross_charge":17.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAPSAICIN 0.025 % TOPICAL CREAM [1350]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-2525-25","type":"NDC"}],"standard_charges":[{"gross_charge":8.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0548-5900-00","type":"NDC"}],"standard_charges":[{"gross_charge":61.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL [29676]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-3865-75","type":"NDC"}],"standard_charges":[{"gross_charge":2.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-106-67","type":"NDC"}],"standard_charges":[{"gross_charge":4.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":27.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43825-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"48102-057-11","type":"NDC"}],"standard_charges":[{"gross_charge":27.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DOXAZOSIN 1 MG TABLET [9894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-222-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MVI, ADULT WITH VIT K 3300 UNIT-150 MCG WRAPPER [339599]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54643-5649-1","type":"NDC"}],"standard_charges":[{"gross_charge":28.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PEGFILGRASTIM (NEULASTA) 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-190-01","type":"NDC"}],"standard_charges":[{"gross_charge":11210.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [192863]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57894-503-01","type":"NDC"}],"standard_charges":[{"gross_charge":29075.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-595-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-830-42","type":"NDC"}],"standard_charges":[{"gross_charge":26.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MINERAL OIL, LIGHT STERILE [191645]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6332325410","type":"NDC"}],"standard_charges":[{"gross_charge":26.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-487-07","type":"NDC"}],"standard_charges":[{"gross_charge":32.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-BUPIVACAINE 0.25%-LIDOCAINE 1%-EPINEPHRINE 1:1,000 SYRINGE [440017]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-489-27","type":"NDC"}],"standard_charges":[{"gross_charge":5.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5216-7","type":"NDC"}],"standard_charges":[{"gross_charge":103.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1781-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION [453]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9888-80","type":"NDC"}],"standard_charges":[{"gross_charge":4.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0004-15","type":"NDC"}],"standard_charges":[{"gross_charge":7.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION [7321]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0054-03","type":"NDC"}],"standard_charges":[{"gross_charge":8.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-6060-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1631-10","type":"NDC"}],"standard_charges":[{"gross_charge":34.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6132-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.1 MG/ML INTRAVENOUS SOLUTION [191549]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6245-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR 200 MG CAPSULE [8969]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5789-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SERTRALINE 50 MG TABLET [11351]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6925-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TORSEMIDE 10 MG TABLET [18292]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-530-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-707-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-730-30","type":"NDC"}],"standard_charges":[{"gross_charge":6.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ISOSORBIDE DINITRATE 10 MG TABLET [4064]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49884-021-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DRONABINOL 2.5 MG CAPSULE [9904]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-375-11","type":"NDC"}],"standard_charges":[{"gross_charge":11.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [30807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61553-112-52","type":"NDC"}],"standard_charges":[{"gross_charge":14.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MORPHINE 15 MG IMMEDIATE RELEASE TABLET [5178]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0235-24","type":"NDC"}],"standard_charges":[{"gross_charge":1.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROSUVASTATIN 10 MG TABLET [35134]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0310-7570-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0089-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [92895]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3552-48","type":"NDC"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-BUPIVACAINE-EPI/LIDOCAINE-EPI 0.5%-1:200,000 [440051]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-53","type":"NDC"}],"standard_charges":[{"gross_charge":12.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUPHENAZINE 5 MG TABLET [3221]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-1790-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML ORAL SUSPENSION [127341]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0520-74","type":"NDC"}],"standard_charges":[{"gross_charge":33.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-107-68","type":"NDC"}],"standard_charges":[{"gross_charge":6.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-437-91","type":"NDC"}],"standard_charges":[{"gross_charge":2091.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NADOLOL 20 MG TABLET [5330]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-302-95","type":"NDC"}],"standard_charges":[{"gross_charge":5.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-374-12","type":"NDC"}],"standard_charges":[{"gross_charge":8.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-587-59","type":"NDC"}],"standard_charges":[{"gross_charge":2.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-618-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-801-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-204-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [181236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"9999-4007-03","type":"NDC"}],"standard_charges":[{"gross_charge":24.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BRIMONIDINE 0.1 % EYE DROPS [70262]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0023-9321-05","type":"NDC"}],"standard_charges":[{"gross_charge":538.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [121353]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6228-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"12870-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":2.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-501-64","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-937-05","type":"NDC"}],"standard_charges":[{"gross_charge":7.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-730-06","type":"NDC"}],"standard_charges":[{"gross_charge":81.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [124737]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-242-51","type":"NDC"}],"standard_charges":[{"gross_charge":21.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-222-01","type":"NDC"}],"standard_charges":[{"gross_charge":15025.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [181361]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57894-054-27","type":"NDC"}],"standard_charges":[{"gross_charge":6144.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57894-160-01","type":"NDC"}],"standard_charges":[{"gross_charge":1316.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PRAMIPEXOLE 0.5 MG TABLET [22719]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-581-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LURASIDONE 20 MG TABLET [113587]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-747-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEMETREXED DISODIUM 1,000 MG INTRAVENOUS POWDER FOR SOLUTION [199304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-148-51","type":"NDC"}],"standard_charges":[{"gross_charge":514.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-505-01","type":"NDC"}],"standard_charges":[{"gross_charge":27.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-401-41","type":"NDC"}],"standard_charges":[{"gross_charge":14.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-BUPIVACAINE 0.25%-LIDOCAINE 1% SYRINGE [440009]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-9007-50","type":"NDC"}],"standard_charges":[{"gross_charge":6.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION [130943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0013-05","type":"NDC"}],"standard_charges":[{"gross_charge":117.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION [1312]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9180-01","type":"NDC"}],"standard_charges":[{"gross_charge":21.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-9378-88","type":"NDC"}],"standard_charges":[{"gross_charge":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6231-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 5 MG TABLET [36438]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-784-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DRONABINOL 2.5 MG CAPSULE [9904]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-867-06","type":"NDC"}],"standard_charges":[{"gross_charge":5.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-707-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-233-00","type":"NDC"}],"standard_charges":[{"gross_charge":31.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOZAPINE 100 MG TABLET [9647]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-415-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-534-40","type":"NDC"}],"standard_charges":[{"gross_charge":25.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-77","type":"NDC"}],"standard_charges":[{"gross_charge":13.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64380-766-21","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARGATROBAN 50 MG/50 ML (1 MG/ML) WRAPPER [508177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-429-50","type":"NDC"}],"standard_charges":[{"gross_charge":207.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-118-50","type":"NDC"}],"standard_charges":[{"gross_charge":250.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 10 MG/ML INJECTION SOLUTION [4236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-181-00","type":"NDC"}],"standard_charges":[{"gross_charge":29.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-617-30","type":"NDC"}],"standard_charges":[{"gross_charge":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INDOMETHACIN 25 MG CAPSULE [3897]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-406-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-601-01","type":"NDC"}],"standard_charges":[{"gross_charge":40.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY [16070]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-0045-44","type":"NDC"}],"standard_charges":[{"gross_charge":49.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETRACAINE HCL (PF) 0.5 % EYE DROPS [131372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0741-14","type":"NDC"}],"standard_charges":[{"gross_charge":36.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0795-15","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DICLOXACILLIN 250 MG CAPSULE [2414]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3123-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-7415-51","type":"NDC"}],"standard_charges":[{"gross_charge":2.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BISACODYL 10 MG RECTAL SUPPOSITORY [1080]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0574-7050-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MELATONIN 3 MG TABLET [16830]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026852415","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-505-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"52380-1905-4","type":"NDC"}],"standard_charges":[{"gross_charge":68.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCHLOROTHIAZIDE 25 MG TABLET [3720]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-593-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINERAL OIL [94447]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6332325410","type":"NDC"}],"standard_charges":[{"gross_charge":26.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14984]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-463-01","type":"NDC"}],"standard_charges":[{"gross_charge":46.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-614-00","type":"NDC"}],"standard_charges":[{"gross_charge":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-700-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67877-547-88","type":"NDC"}],"standard_charges":[{"gross_charge":41.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 200 MG TABLET [10374]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-382-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [130348]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8068116000","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COLLOIDAL OATMEAL TOPICAL PACKET [81870]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8137003640","type":"NDC"}],"standard_charges":[{"gross_charge":2.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERIPARATIDE 20 MCG/DOSE (560 MCG/2.24 ML) SUBCUTANEOUS PEN INJECTOR [104264]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8400-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0116-4005-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":4.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK [128040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0551-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435179750","type":"NDC"}],"standard_charges":[{"gross_charge":143.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6135-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION [12748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-187-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":25.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-299-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55111-688-52","type":"NDC"}],"standard_charges":[{"gross_charge":186.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-226-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-434-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"58160-811-43","type":"NDC"}],"standard_charges":[{"gross_charge":183.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-645-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOCLOPRAMIDE 10 MG TABLET [5005]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-676-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68462-469-40","type":"NDC"}],"standard_charges":[{"gross_charge":6.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70092-1552-07","type":"NDC"}],"standard_charges":[{"gross_charge":3.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-6300-5","type":"NDC"}],"standard_charges":[{"gross_charge":74.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CODEINE SULFATE 30 MG TABLET [1802]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0244-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 5 MG TABLET [4398]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8496-19","type":"NDC"}],"standard_charges":[{"gross_charge":4.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SIMPLE SYRUP [7242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0395266116","type":"NDC"}],"standard_charges":[{"gross_charge":35.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOLNAFTATE 1 % TOPICAL CREAM [8020]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1315-43","type":"NDC"}],"standard_charges":[{"gross_charge":2.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOCINOLONE 0.025 % TOPICAL OINTMENT [3185]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0224-15","type":"NDC"}],"standard_charges":[{"gross_charge":57.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 10 MG TABLET [3698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6440-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-931-11","type":"NDC"}],"standard_charges":[{"gross_charge":56.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-749-76","type":"NDC"}],"standard_charges":[{"gross_charge":4.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [11634]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47335-931-40","type":"NDC"}],"standard_charges":[{"gross_charge":11.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-234-10","type":"NDC"}],"standard_charges":[{"gross_charge":14.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 0.5 % EYE DROPS [19733]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-1003-1","type":"NDC"}],"standard_charges":[{"gross_charge":31.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6229-4","type":"NDC"}],"standard_charges":[{"gross_charge":83.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65219-436-02","type":"NDC"}],"standard_charges":[{"gross_charge":10.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-062-42","type":"NDC"}],"standard_charges":[{"gross_charge":72.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [196803]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71258-022-01","type":"NDC"}],"standard_charges":[{"gross_charge":1862.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3321-0","type":"NDC"}],"standard_charges":[{"gross_charge":26.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8452176708","type":"NDC"}],"standard_charges":[{"gross_charge":3.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.5 MG/5 ML (100 MCG/ML)IN 0.9 % SOD.CHLORIDE IV SYRINGE [130890]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-17","type":"NDC"}],"standard_charges":[{"gross_charge":30.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-0221-01","type":"NDC"}],"standard_charges":[{"gross_charge":47.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0054-0742-87","type":"NDC"}],"standard_charges":[{"gross_charge":42.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS [16014]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0811-04","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0552-62","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0472-0381-15","type":"NDC"}],"standard_charges":[{"gross_charge":31.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4602-25","type":"NDC"}],"standard_charges":[{"gross_charge":6.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [121784]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3059-72","type":"NDC"}],"standard_charges":[{"gross_charge":7.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"11523-7234-1","type":"NDC"}],"standard_charges":[{"gross_charge":3.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [129774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-634-02","type":"NDC"}],"standard_charges":[{"gross_charge":1573.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION [31177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16714-294-01","type":"NDC"}],"standard_charges":[{"gross_charge":42.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 10 MG TABLET [3772]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"23155-500-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-150-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION [9941]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-148-01","type":"NDC"}],"standard_charges":[{"gross_charge":190.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-244-67","type":"NDC"}],"standard_charges":[{"gross_charge":6.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 10 MG TABLET [3733]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-582-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-781-11","type":"NDC"}],"standard_charges":[{"gross_charge":12.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN V POTASSIUM 250 MG TABLET [6092]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-175-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY [16071]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69238-2017-2","type":"NDC"}],"standard_charges":[{"gross_charge":94.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [165023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1712-1","type":"NDC"}],"standard_charges":[{"gross_charge":64.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION (PEDIATRIC) [450167]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0049-0013-81","type":"NDC"}],"standard_charges":[{"gross_charge":20.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 2 GRAM/100 ML IN DEXTROSE(ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [175908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3508-41","type":"NDC"}],"standard_charges":[{"gross_charge":27.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1631-10","type":"NDC"}],"standard_charges":[{"gross_charge":34.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4902-34","type":"NDC"}],"standard_charges":[{"gross_charge":50.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [165400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6149-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3545-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET [9285]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7205-46","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"12870-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42806-147-31","type":"NDC"}],"standard_charges":[{"gross_charge":33.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-252-20","type":"NDC"}],"standard_charges":[{"gross_charge":3.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETAMINE 10 MG/ML INJECTION SOLUTION [4236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-438-01","type":"NDC"}],"standard_charges":[{"gross_charge":28.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-738-42","type":"NDC"}],"standard_charges":[{"gross_charge":14.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 200 MCG TABLET [10629]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-746-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 300 MG CAPSULE [18308]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-236-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1531-1","type":"NDC"}],"standard_charges":[{"gross_charge":4697.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-600-41","type":"NDC"}],"standard_charges":[{"gross_charge":0.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VONOPRAZAN 20 MG TABLET [205065]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"81520-200-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [177828]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-2291-11","type":"NDC"}],"standard_charges":[{"gross_charge":6561.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0357-05","type":"NDC"}],"standard_charges":[{"gross_charge":20.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [167937]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2308-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":13.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0832-6045-50","type":"NDC"}],"standard_charges":[{"gross_charge":65.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6773-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLOBETASOL 0.05 % TOPICAL OINTMENT [9631]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"42291-077-15","type":"NDC"}],"standard_charges":[{"gross_charge":7.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIVAROXABAN 2.5 MG TABLET [188292]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50458-577-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-458-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION [191769]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51144-030-01","type":"NDC"}],"standard_charges":[{"gross_charge":12446.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [128574]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54288-103-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [165644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57894-350-01","type":"NDC"}],"standard_charges":[{"gross_charge":5784.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET [8958]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-672-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-03","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OR-PHENYLEPHRINE INFUSION 10 MG/250 ML (40 MCG/ML) IN NS (BEV) [444689]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-751-00","type":"NDC"}],"standard_charges":[{"gross_charge":862.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-002-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL IV INJECTION [410075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68001-525-27","type":"NDC"}],"standard_charges":[{"gross_charge":71.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [119246]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-157-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72888-125-26","type":"NDC"}],"standard_charges":[{"gross_charge":26.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-9702-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION [125923]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5922-16","type":"NDC"}],"standard_charges":[{"gross_charge":27.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9501-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"},{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6008-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DONEPEZIL 5 MG TABLET [18786]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6477-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7193-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYPROMELLOSE 2.5 % EYE DROPS [38092]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-064-12","type":"NDC"}],"standard_charges":[{"gross_charge":49.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-402-66","type":"NDC"}],"standard_charges":[{"gross_charge":3.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MELATONIN 3 MG TABLET [16830]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5003561502","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-299-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-4048-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-275-62","type":"NDC"}],"standard_charges":[{"gross_charge":9.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6498033901","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-521-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARFILZOMIB 60 MG INTRAVENOUS SOLUTION [117047]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"76075-101-01","type":"NDC"}],"standard_charges":[{"gross_charge":9429.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [82301]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-0302-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0078-0876-01","type":"NDC"}],"standard_charges":[{"gross_charge":722.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION [88505]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-2823-94","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [28400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0013-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"METOPROLOL TARTRATE 25 MG TABLET [37637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6340-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERITONEAL DIALYSIS 28 AND ICODEXTRIN 7.5 % CA 3.5 MEQ/L-MAG 0.5 MEQ/L [128539]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0679-52","type":"NDC"}],"standard_charges":[{"gross_charge":426.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":55.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-698-11","type":"NDC"}],"standard_charges":[{"gross_charge":458.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-707-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALTEPLASE 1 MG SOLUTION FOR INJECTION [400543]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-044-13","type":"NDC"}],"standard_charges":[{"gross_charge":10116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6156-0","type":"NDC"}],"standard_charges":[{"gross_charge":4.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-760-40","type":"NDC"}],"standard_charges":[{"gross_charge":2.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 0.5 % EYE DROPS [19733]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-126-05","type":"NDC"}],"standard_charges":[{"gross_charge":18.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-309-16","type":"NDC"}],"standard_charges":[{"gross_charge":36.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"INDOCYANINE GREEN 1.25 MG/ML INJECTION [632141]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-424-01","type":"NDC"}],"standard_charges":[{"gross_charge":376.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8373079830","type":"NDC"}],"standard_charges":[{"gross_charge":47.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0115-1468-53","type":"NDC"}],"standard_charges":[{"gross_charge":14.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-1800-32","type":"NDC"}],"standard_charges":[{"gross_charge":7.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7510-20","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3451-70","type":"NDC"}],"standard_charges":[{"gross_charge":4.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFPODOXIME 100 MG TABLET [9468]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-394-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPINIROLE 1 MG TABLET [21689]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-270-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-252-51","type":"NDC"}],"standard_charges":[{"gross_charge":984.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TENECTEPLASE 50 MG INJECTION FOR ACUTE ISCHEMIC STROKE [632538]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-037-06","type":"NDC"}],"standard_charges":[{"gross_charge":22427.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50742-447-45","type":"NDC"}],"standard_charges":[{"gross_charge":207.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [193630]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50742-520-05","type":"NDC"}],"standard_charges":[{"gross_charge":756.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MELATONIN 3 MG TABLET [16830]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5789686406","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIGOXIN 250 MCG (0.25 MG) TABLET [2445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-551-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DAPSONE 100 MG TABLET [2131]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64980-566-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-707-18","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION [4985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-38","type":"NDC"}],"standard_charges":[{"gross_charge":500.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREGABALIN 100 MG CAPSULE [42165]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-1015-68","type":"NDC"}],"standard_charges":[{"gross_charge":28.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CILOSTAZOL 100 MG TABLET [24474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-2064-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1323-05","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4777-02","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1052-24","type":"NDC"}],"standard_charges":[{"gross_charge":14.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6125-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG CAPSULE [10070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7346-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-0493-04","type":"NDC"}],"standard_charges":[{"gross_charge":155.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17478-069-14","type":"NDC"}],"standard_charges":[{"gross_charge":8.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-033-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ARIPIPRAZOLE 10 MG TABLET [34369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-556-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 5 % TOPICAL OINTMENT [41831]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-3020-9","type":"NDC"}],"standard_charges":[{"gross_charge":69.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [27490]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"53489-369-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-788-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-229-05","type":"NDC"}],"standard_charges":[{"gross_charge":30.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-22","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-275-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 2 % EYE DROPS [6280]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-191-01","type":"NDC"}],"standard_charges":[{"gross_charge":94.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-301-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0008-0833-03","type":"NDC"}],"standard_charges":[{"gross_charge":30.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV [24329]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4520-02","type":"NDC"}],"standard_charges":[{"gross_charge":17.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-06","type":"NDC"}],"standard_charges":[{"gross_charge":9.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [165739]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0573-2871-93","type":"NDC"}],"standard_charges":[{"gross_charge":16.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN HCL 150 MG CAPSULE [1740]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5959-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7280-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 0.5 MG TABLET [9637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-136-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACOSAMIDE 100 MG TABLET [96969]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-813-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-116-25","type":"NDC"}],"standard_charges":[{"gross_charge":4.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57237-316-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-61","type":"NDC"}],"standard_charges":[{"gross_charge":81.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-30","type":"NDC"}],"standard_charges":[{"gross_charge":13.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [106363]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-491-57","type":"NDC"}],"standard_charges":[{"gross_charge":40.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-649-07","type":"NDC"}],"standard_charges":[{"gross_charge":319.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-339-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-940-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70710-1833-1","type":"NDC"}],"standard_charges":[{"gross_charge":261.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMMONIUM LACTATE 12 % LOTION [10380]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"7139901408","type":"NDC"}],"standard_charges":[{"gross_charge":8.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN IV SYRINGE 2 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450420]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"9999-9999-42","type":"NDC"}],"standard_charges":[{"gross_charge":2.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RASAGILINE 1 MG TABLET [76481]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3061-56","type":"NDC"}],"standard_charges":[{"gross_charge":5.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1870-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0281-0326-08","type":"NDC"}],"standard_charges":[{"gross_charge":6.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1778-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3815-11","type":"NDC"}],"standard_charges":[{"gross_charge":22.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4444-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9904-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0376-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24201-400-02","type":"NDC"}],"standard_charges":[{"gross_charge":2115.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [129971]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-673-77","type":"NDC"}],"standard_charges":[{"gross_charge":15.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR [9773]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"45802-433-21","type":"NDC"}],"standard_charges":[{"gross_charge":14.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL 10 MG TABLET [6656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-662-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-458-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-225-05","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE [108048]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-111-01","type":"NDC"}],"standard_charges":[{"gross_charge":3022.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-30","type":"NDC"}],"standard_charges":[{"gross_charge":13.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION [32855]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-446-10","type":"NDC"}],"standard_charges":[{"gross_charge":69.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-436-91","type":"NDC"}],"standard_charges":[{"gross_charge":15.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREGABALIN 75 MG CAPSULE [42164]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-1014-68","type":"NDC"}],"standard_charges":[{"gross_charge":28.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3612-50","type":"NDC"}],"standard_charges":[{"gross_charge":29.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-54","type":"NDC"}],"standard_charges":[{"gross_charge":24.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9094-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-3508-54","type":"NDC"}],"standard_charges":[{"gross_charge":27.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6175-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-101-67","type":"NDC"}],"standard_charges":[{"gross_charge":2.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [189180]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-121-07","type":"NDC"}],"standard_charges":[{"gross_charge":190.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DONEPEZIL 5 MG TABLET [18786]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-275-09","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORTRIPTYLINE 10 MG CAPSULE [5674]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-281-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIFAMPIN 300 MG CAPSULE [11293]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-586-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62037-999-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-17","type":"NDC"}],"standard_charges":[{"gross_charge":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-313-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-203-04","type":"NDC"}],"standard_charges":[{"gross_charge":1.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71506-028-59","type":"NDC"}],"standard_charges":[{"gross_charge":4.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0046-0872-21","type":"NDC"}],"standard_charges":[{"gross_charge":1268.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 0.5 MG TABLET [2322]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8179-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [29302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0759-08","type":"NDC"}],"standard_charges":[{"gross_charge":108.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IODIXANOL 270 MG IODINE/ML INTRAVENOUS SOLUTION [17594]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-2222-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1560-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0400-37","type":"NDC"}],"standard_charges":[{"gross_charge":6.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-5894-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ABIRATERONE 250 MG TABLET [109776]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6948-04","type":"NDC"}],"standard_charges":[{"gross_charge":8.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7983-61","type":"NDC"}],"standard_charges":[{"gross_charge":10.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-TRANEXEMIC ACID INFUSION 3,000 MG/250 ML IN NS [975035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-008-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-041-64","type":"NDC"}],"standard_charges":[{"gross_charge":527.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-416-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ABIRATERONE 250 MG TABLET [109776]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-790-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 1 % EYE DROPS [6279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69238-1745-8","type":"NDC"}],"standard_charges":[{"gross_charge":174.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-021-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.2 % EYE DROPS [17881]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-231-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-41","type":"NDC"}],"standard_charges":[{"gross_charge":8.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 2 MG/ML INJECTION WRAPPER [339565]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-004-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9331-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [92895]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3552-48","type":"NDC"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1215-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7101-67","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [27507]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-3510-54","type":"NDC"}],"standard_charges":[{"gross_charge":57.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 400 MG CAPSULE [18307]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6667-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7183-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-345-33","type":"NDC"}],"standard_charges":[{"gross_charge":22.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY [16070]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-398-30","type":"NDC"}],"standard_charges":[{"gross_charge":101.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-580-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [116596]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-145-01","type":"NDC"}],"standard_charges":[{"gross_charge":19509.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXEPIN 25 MG CAPSULE [2611]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-437-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 3,000 UNIT/ML INJECTION SOLUTION [9940]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-267-01","type":"NDC"}],"standard_charges":[{"gross_charge":142.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6157-0","type":"NDC"}],"standard_charges":[{"gross_charge":5.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 80 MG CHEWABLE TABLET [7227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-225-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOSPORINE 25 MG CAPSULE [9707]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-879-95","type":"NDC"}],"standard_charges":[{"gross_charge":9.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALPRAZOLAM 0.25 MG TABLET [324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2027-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0512-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1414-60","type":"NDC"}],"standard_charges":[{"gross_charge":28.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3815-12","type":"NDC"}],"standard_charges":[{"gross_charge":26.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6044-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7279-66","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERITONEAL DIALYSIS SOLN 7 (DIANEAL) DEXTR 2.5-CA 2.5 MEQ/L-MG 0.5 MEQ/L [27800]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0430-53","type":"NDC"}],"standard_charges":[{"gross_charge":142.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 20 MG TABLET [11111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-666-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 10 MG TABLET [11110]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-169-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-186-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-27","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-16","type":"NDC"}],"standard_charges":[{"gross_charge":4.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BENZTROPINE 0.5 MG TABLET [998]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-381-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 5 MG TABLET [12803]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-928-95","type":"NDC"}],"standard_charges":[{"gross_charge":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HUMAN PROTHROMBIN COMPLEX (BALFAXAR) CONCENTRATE-LANS 500 UNIT IV SOLUTION [203925]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68982-261-01","type":"NDC"}],"standard_charges":[{"gross_charge":1829.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-136-03","type":"NDC"}],"standard_charges":[{"gross_charge":40.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8373079830","type":"NDC"}],"standard_charges":[{"gross_charge":47.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0795-15","type":"NDC"}],"standard_charges":[{"gross_charge":10.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-16","type":"NDC"}],"standard_charges":[{"gross_charge":7.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0376-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3545-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 200 MG TABLET [3841]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7914-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-50","type":"NDC"}],"standard_charges":[{"gross_charge":7103.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"32909-750-03","type":"NDC"}],"standard_charges":[{"gross_charge":15.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-015-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-120-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-718-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRANEXAMIC ACID 650 MG TABLET [104576]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-750-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 125 MG TABLET,DELAYED RELEASE [2551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-857-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-17","type":"NDC"}],"standard_charges":[{"gross_charge":10.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-433-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-400-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 0.2 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN [130864]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-5035-1","type":"NDC"}],"standard_charges":[{"gross_charge":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.4 MG/10 ML (40 MCG/ML) IN 0.9 %SOD.CHLORIDE IV SYRINGE [131065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71506-040-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-5781-1","type":"NDC"}],"standard_charges":[{"gross_charge":9.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-8018-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9161-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 50 MG/ML INJECTION SOLUTION [4238]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9508-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9553-01","type":"NDC"}],"standard_charges":[{"gross_charge":60.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1709-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPHENIDATE ER 54 MG TABLET,EXTENDED RELEASE 24 HR [29388]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0154-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1263-28","type":"NDC"}],"standard_charges":[{"gross_charge":12.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6455-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7237-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION [8982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-0495-05","type":"NDC"}],"standard_charges":[{"gross_charge":95.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-11","type":"NDC"}],"standard_charges":[{"gross_charge":2062.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 0.1 % TOPICAL CREAM [3423]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-056-35","type":"NDC"}],"standard_charges":[{"gross_charge":109.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUMATRIPTAN 50 MG TABLET [15328]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-292-09","type":"NDC"}],"standard_charges":[{"gross_charge":1.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METFORMIN 500 MG TABLET [10544]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-155-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID WRAPPER [777218]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6961800815","type":"NDC"}],"standard_charges":[{"gross_charge":2.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EYE DROPS [19746]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-613-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION WRAPPER [421035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0078-0508-83","type":"NDC"}],"standard_charges":[{"gross_charge":256.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN NPH-REGULAR 70-30 MIX 100 UNIT/ML (U-100) SUBCUTANEOUS SUSP [10286]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0169-1837-11","type":"NDC"}],"standard_charges":[{"gross_charge":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SYRINGE [123669]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1312-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6057-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN IV 12 MG/ML IN D5W (PEDIATRIC-PREMIX) [977176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG CHEWABLE TABLET [8941]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6645-24","type":"NDC"}],"standard_charges":[{"gross_charge":0.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-264-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE [27644]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-339-60","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET [76950]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"4843310401","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-644-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-800-40","type":"NDC"}],"standard_charges":[{"gross_charge":2.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-229-01","type":"NDC"}],"standard_charges":[{"gross_charge":30.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION [6429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-965-05","type":"NDC"}],"standard_charges":[{"gross_charge":5.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CINACALCET 30 MG TABLET [38100]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-883-04","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-692-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-011-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3469-1","type":"NDC"}],"standard_charges":[{"gross_charge":74.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0179-8012-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHADONE 5 MG TABLET [4954]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-5755-23","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4902-34","type":"NDC"}],"standard_charges":[{"gross_charge":49.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 100 MG TABLET [10373]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0605-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERPHENAZINE 4 MG TABLET [6158]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1047-13","type":"NDC"}],"standard_charges":[{"gross_charge":3.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3246-02","type":"NDC"}],"standard_charges":[{"gross_charge":24.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6007-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"QUETIAPINE 100 MG TABLET [21824]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6640-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIGOXIN 250 MCG (0.25 MG) TABLET [2445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-591-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO)INTRAVENOUS PIGGYBACK (FOR 100 MG/50 ML DOSE) [480069]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-184-82","type":"NDC"}],"standard_charges":[{"gross_charge":11.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-415-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER [339457]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-611-01","type":"NDC"}],"standard_charges":[{"gross_charge":51.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOBETASOL 0.05 % TOPICAL OINTMENT [9631]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"50383-268-15","type":"NDC"}],"standard_charges":[{"gross_charge":229.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-710-21","type":"NDC"}],"standard_charges":[{"gross_charge":5299.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-863-42","type":"NDC"}],"standard_charges":[{"gross_charge":3.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZONISAMIDE 25 MG CAPSULE [36987]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-242-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ATROPINE 1 MG/ML INJECTION SOLUTION WRAPPER [339091]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-641-01","type":"NDC"}],"standard_charges":[{"gross_charge":20.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [6445]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71740-112-30","type":"NDC"}],"standard_charges":[{"gross_charge":1192.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 175 MCG TABLET [10406]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-7070-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN 0.3 % EYE OINTMENT [19769]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0078-0813-01","type":"NDC"}],"standard_charges":[{"gross_charge":661.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [108096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9022-02","type":"NDC"}],"standard_charges":[{"gross_charge":98.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LAMOTRIGINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [97967]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0757-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-00","type":"NDC"}],"standard_charges":[{"gross_charge":10.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0031-25","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3290-09","type":"NDC"}],"standard_charges":[{"gross_charge":12.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108047]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-111-01","type":"NDC"}],"standard_charges":[{"gross_charge":3022.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLONAZEPAM 1 MG TABLET [9638]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-872-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-20","type":"NDC"}],"standard_charges":[{"gross_charge":44.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION [16169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-418-20","type":"NDC"}],"standard_charges":[{"gross_charge":749.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-434-41","type":"NDC"}],"standard_charges":[{"gross_charge":33.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAT EMULSION 20 % INTRAVENOUS (W/CONTEXTS) [339140]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-533-01","type":"NDC"}],"standard_charges":[{"gross_charge":39.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-507-53","type":"NDC"}],"standard_charges":[{"gross_charge":20.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68001-525-32","type":"NDC"}],"standard_charges":[{"gross_charge":142.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LISINOPRIL 2.5 MG TABLET [13089]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-765-95","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [193439]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68727-712-01","type":"NDC"}],"standard_charges":[{"gross_charge":23850.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARFILZOMIB 10 MG INTRAVENOUS SOLUTION [187719]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"76075-103-01","type":"NDC"}],"standard_charges":[{"gross_charge":1571.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMIODARONE 100 MG TABLET [36959]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-0144-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-38","type":"NDC"}],"standard_charges":[{"gross_charge":4.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0512-23","type":"NDC"}],"standard_charges":[{"gross_charge":0.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-424-06","type":"NDC"}],"standard_charges":[{"gross_charge":194.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-420-20","type":"NDC"}],"standard_charges":[{"gross_charge":75.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-009-24","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-131-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE [27974]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"4910038164","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 25 MCG TABLET [4420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-444-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-30","type":"NDC"}],"standard_charges":[{"gross_charge":13.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-285-04","type":"NDC"}],"standard_charges":[{"gross_charge":109.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-299-00","type":"NDC"}],"standard_charges":[{"gross_charge":110.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR 200 MG CAPSULE [8969]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-107-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-157-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"TAMOXIFEN 10 MG TABLET [7711]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0144-91","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [2361]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1775-40","type":"NDC"}],"standard_charges":[{"gross_charge":42.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-53","type":"NDC"}],"standard_charges":[{"gross_charge":12.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1263-28","type":"NDC"}],"standard_charges":[{"gross_charge":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL 1 MG TABLET [3579]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-1520-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 200 MG TABLET [10374]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7452-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"27241-249-49","type":"NDC"}],"standard_charges":[{"gross_charge":78.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"43598-210-25","type":"NDC"}],"standard_charges":[{"gross_charge":13.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOLUTEGRAVIR 50 MG TABLET [165779]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49702-228-13","type":"NDC"}],"standard_charges":[{"gross_charge":222.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 25 MG TABLET [37637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-255-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [30070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-467-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6148-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"DILTIAZEM 30 MG TABLET [2475]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-717-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHOSUXIMIDE 250 MG CAPSULE [9989]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-878-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-056-99","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67919-012-02","type":"NDC"}],"standard_charges":[{"gross_charge":360.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 1 % EYE DROPS [6279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-181-01","type":"NDC"}],"standard_charges":[{"gross_charge":142.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-410-88","type":"NDC"}],"standard_charges":[{"gross_charge":15.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-3843-71","type":"NDC"}],"standard_charges":[{"gross_charge":356.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION WRAPPER [421038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [10049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4688-22","type":"NDC"}],"standard_charges":[{"gross_charge":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0526-06","type":"NDC"}],"standard_charges":[{"gross_charge":13.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-591-80","type":"NDC"}],"standard_charges":[{"gross_charge":179.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14362-0111-3","type":"NDC"}],"standard_charges":[{"gross_charge":56.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BACLOFEN 10 MG TABLET [860]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-071-04","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-900-99","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE [167958]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2420869790","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 125 MG CAPSULE [11628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42494-450-20","type":"NDC"}],"standard_charges":[{"gross_charge":4.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-057-01","type":"NDC"}],"standard_charges":[{"gross_charge":251.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MEGESTROL 400 MG/10 ML (40 MG/ML) ORAL SUSPENSION [10521]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60432-126-08","type":"NDC"}],"standard_charges":[{"gross_charge":45.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 2 MG TABLET [2326]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-773-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61958-0901-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [11634]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-438-00","type":"NDC"}],"standard_charges":[{"gross_charge":13.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-246-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-475-47","type":"NDC"}],"standard_charges":[{"gross_charge":4.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC99M MEDRONATE PSD UT 30 MCI [450038]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9002-11","type":"NDC"}],"standard_charges":[{"gross_charge":367.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"CEFADROXIL 500 MG CAPSULE [9436]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3196-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [165023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9557-12","type":"NDC"}],"standard_charges":[{"gross_charge":74.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-8005-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SYRINGE [124908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-17","type":"NDC"}],"standard_charges":[{"gross_charge":8.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6125-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6244-01","type":"NDC"}],"standard_charges":[{"gross_charge":46.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET [1300]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904188361","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6627-35","type":"NDC"}],"standard_charges":[{"gross_charge":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TIMOLOL MALEATE 0.5 % EYE DROPS [11562]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-288-10","type":"NDC"}],"standard_charges":[{"gross_charge":15.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"49348-279-72","type":"NDC"}],"standard_charges":[{"gross_charge":11.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LETROZOLE 2.5 MG TABLET [21509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-476-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60219-2348-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-803-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-807-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-411-12","type":"NDC"}],"standard_charges":[{"gross_charge":3.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERBINAFINE HCL 250 MG TABLET [12724]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-079-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66794-237-02","type":"NDC"}],"standard_charges":[{"gross_charge":24.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORGESTREL 0.3 MG-ETHINYL ESTRADIOL 30 MCG TABLET [10752]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-895-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9251-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET [94158]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0223-1760-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0089-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-9175-76","type":"NDC"}],"standard_charges":[{"gross_charge":45.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1630-15","type":"NDC"}],"standard_charges":[{"gross_charge":28.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 3.125 MG TABLET [18551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6300-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREGABALIN 75 MG CAPSULE [42164]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7000-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 10 MG TABLET [9506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-799-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION [93052]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"3290994503","type":"NDC"}],"standard_charges":[{"gross_charge":0.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-246-58","type":"NDC"}],"standard_charges":[{"gross_charge":848.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EAR DROPS [22257]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-025-05","type":"NDC"}],"standard_charges":[{"gross_charge":34.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERCONAZOLE 0.8 % VAGINAL CREAM [11511]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1302-0","type":"NDC"}],"standard_charges":[{"gross_charge":58.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-188-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 3,000 UNIT/ML INJECTION SOLUTION [9940]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59676-303-00","type":"NDC"}],"standard_charges":[{"gross_charge":221.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM-SODIUM PHOSPHATES ORAL SUSPENSION (50 MG/ML ELEMENTARY PHOS) [978496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6025800615","type":"NDC"}],"standard_charges":[{"gross_charge":26.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-719-95","type":"NDC"}],"standard_charges":[{"gross_charge":3.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALACYCLOVIR 500 MG TABLET [13133]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-215-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-41","type":"NDC"}],"standard_charges":[{"gross_charge":8.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-302-41","type":"NDC"}],"standard_charges":[{"gross_charge":3.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0004-0802-85","type":"NDC"}],"standard_charges":[{"gross_charge":182.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0049-0014-81","type":"NDC"}],"standard_charges":[{"gross_charge":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-2912-01","type":"NDC"}],"standard_charges":[{"gross_charge":82.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0054-15","type":"NDC"}],"standard_charges":[{"gross_charge":11.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-3243-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6102-18","type":"NDC"}],"standard_charges":[{"gross_charge":5.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0031-25","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ASPIRIN 300 MG RECTAL SUPPOSITORY [693]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0574-7034-12","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-600-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42023-201-01","type":"NDC"}],"standard_charges":[{"gross_charge":194.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-130-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"45802-410-59","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ALPRAZOLAM 0.25 MG TABLET [324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-3719-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 250 MG TABLET [20943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-742-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"METHYLPHENIDATE 10 MG TABLET [4986]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-823-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MOXIFLOXACIN 0.5 % VISCOUS EYE DROPS [108159]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68180-421-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1457-1","type":"NDC"}],"standard_charges":[{"gross_charge":39.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":1043.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WHITE PETROLATUM TOPICAL OINTMENT IN PACKET [132649]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"99999-4007-18","type":"NDC"}],"standard_charges":[{"gross_charge":13.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-1950-30","type":"NDC"}],"standard_charges":[{"gross_charge":480.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0852-10","type":"NDC"}],"standard_charges":[{"gross_charge":3758.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9660-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9093-37","type":"NDC"}],"standard_charges":[{"gross_charge":1.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4602-25","type":"NDC"}],"standard_charges":[{"gross_charge":6.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17478-404-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-555-55","type":"NDC"}],"standard_charges":[{"gross_charge":19.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOMYCIN 500 MG TABLET [5472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"39822-0310-5","type":"NDC"}],"standard_charges":[{"gross_charge":1.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49348-991-36","type":"NDC"}],"standard_charges":[{"gross_charge":5.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-505-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION [191768]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51144-020-01","type":"NDC"}],"standard_charges":[{"gross_charge":8269.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"COLCHICINE 0.6 MG TABLET [1821]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64764-119-07","type":"NDC"}],"standard_charges":[{"gross_charge":19.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-076-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOPIDOGREL 75 MG TABLET [22142]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-357-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOFETILIDE 125 MCG CAPSULE [26965]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72205-039-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72205-101-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MOMETASONE-FORMOTEROL HFA 100 MCG-5 MCG/ACTUATION AEROSOL INHALER [105698]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"78206-127-02","type":"NDC"}],"standard_charges":[{"gross_charge":166.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 15% IN WATER (D15W) INTRAVENOUS SOLUTION 500 ML [606204]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4003-64","type":"NDC"}],"standard_charges":[{"gross_charge":150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-4184-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1488-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TICAGRELOR 90 MG TABLET [110427]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0186-0777-60","type":"NDC"}],"standard_charges":[{"gross_charge":20.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1263-28","type":"NDC"}],"standard_charges":[{"gross_charge":11.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREDNISONE 1 MG TABLET [6493]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-5335-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"1093969133","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-132-68","type":"NDC"}],"standard_charges":[{"gross_charge":16.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-216-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-491-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACLOFEN 10 MG TABLET [860]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-106-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION [3208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60219-1585-3","type":"NDC"}],"standard_charges":[{"gross_charge":176.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-595-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-30","type":"NDC"}],"standard_charges":[{"gross_charge":13.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-26","type":"NDC"}],"standard_charges":[{"gross_charge":11.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOLIC ACID 1 MG TABLET [3233]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-361-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-421-07","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-93","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0045044406","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION [105940]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-0626-03","type":"NDC"}],"standard_charges":[{"gross_charge":206.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXAZEPAM 10 MG CAPSULE [5930]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2067-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROSUVASTATIN 10 MG TABLET [35134]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0310-0751-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION [112786]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0183-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1162-19","type":"NDC"}],"standard_charges":[{"gross_charge":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6057-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 250 MG TABLET,DELAYED RELEASE [121686]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-586-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-580-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FUROSEMIDE 40 MG TABLET [3295]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-073-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFASALAZINE 500 MG TABLET [7562]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-5000-5","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOCARBAMOL 500 MG TABLET [4971]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-559-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65862-946-01","type":"NDC"}],"standard_charges":[{"gross_charge":55.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-438-95","type":"NDC"}],"standard_charges":[{"gross_charge":23.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71399-0041-1","type":"NDC"}],"standard_charges":[{"gross_charge":5.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 20% IN WATER (D20W) IV SOLN [975218]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4010-76","type":"NDC"}],"standard_charges":[{"gross_charge":150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARTIFICIAL TEAR BOTTLE WRAPPER [632222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0418-81","type":"NDC"}],"standard_charges":[{"gross_charge":15.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9577-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3300-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6013-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6142-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATORVASTATIN 40 MG TABLET [19177]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6292-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":22.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-122-67","type":"NDC"}],"standard_charges":[{"gross_charge":16.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-033-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"46122-724-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIOTHYRONINE 5 MCG TABLET [10443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51862-320-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"52817-811-54","type":"NDC"}],"standard_charges":[{"gross_charge":35.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"58914-501-56","type":"NDC"}],"standard_charges":[{"gross_charge":107.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-494-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [173913]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64896-662-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.00421,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-002-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"71399-0071-1","type":"NDC"}],"standard_charges":[{"gross_charge":8.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 0.5 MG TABLET [9637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72888-152-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGIC MOUTHWASH ORAL SOLUTION [975049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-47","type":"NDC"}],"standard_charges":[{"gross_charge":31.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0781-7296-85","type":"NDC"}],"standard_charges":[{"gross_charge":45.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5448-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6008-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-635-62","type":"NDC"}],"standard_charges":[{"gross_charge":178.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-573-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-248-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCHLOROTHIAZIDE 12.5 MG TABLET [76988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51407-330-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MECLIZINE 12.5 MG TABLET [12024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-775-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [30807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61553-112-52","type":"NDC"}],"standard_charges":[{"gross_charge":23.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE 20 MG TABLET [10855]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-963-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 50 MG/ML ORAL SOLUTION [11630]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65628-208-10","type":"NDC"}],"standard_charges":[{"gross_charge":663.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RALOXIFENE 60 MG TABLET [22143]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-709-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE [38063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-918-95","type":"NDC"}],"standard_charges":[{"gross_charge":15.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69097-319-86","type":"NDC"}],"standard_charges":[{"gross_charge":4.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IMIPRAMINE 50 MG TABLET [3862]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-135-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROSUVASTATIN 20 MG TABLET [35135]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72205-004-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 10 MCG/ML (400 UNIT/ML) ORAL DROPS [96930]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0087086644","type":"NDC"}],"standard_charges":[{"gross_charge":27.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [9774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0638-05","type":"NDC"}],"standard_charges":[{"gross_charge":4.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACOSAMIDE 100 MG TABLET [96969]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0131-2478-35","type":"NDC"}],"standard_charges":[{"gross_charge":52.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [11081]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7865-00","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS (NEONATAL) [450168]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7295-01","type":"NDC"}],"standard_charges":[{"gross_charge":40.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-9105-72","type":"NDC"}],"standard_charges":[{"gross_charge":62.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7237-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [113477]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-637-52","type":"NDC"}],"standard_charges":[{"gross_charge":24.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 10 MG TABLET [34369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-089-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55111-688-52","type":"NDC"}],"standard_charges":[{"gross_charge":186.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE [76334]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-032-01","type":"NDC"}],"standard_charges":[{"gross_charge":5037.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-185-07","type":"NDC"}],"standard_charges":[{"gross_charge":2.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-198-05","type":"NDC"}],"standard_charges":[{"gross_charge":349.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68001-265-22","type":"NDC"}],"standard_charges":[{"gross_charge":25.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE [12933]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-450-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION [8982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5218-0","type":"NDC"}],"standard_charges":[{"gross_charge":98.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-301-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-107-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION WRAPPER [425002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9334-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAT EMULSION 20 % INTRAVENOUS [10014]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4460-30","type":"NDC"}],"standard_charges":[{"gross_charge":71.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7510-20","type":"NDC"}],"standard_charges":[{"gross_charge":9.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1215-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1560-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-7415-51","type":"NDC"}],"standard_charges":[{"gross_charge":2.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MEGESTROL 40 MG TABLET [4871]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0607-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7983-61","type":"NDC"}],"standard_charges":[{"gross_charge":10.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-1000-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-466-35","type":"NDC"}],"standard_charges":[{"gross_charge":18.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-155-20","type":"NDC"}],"standard_charges":[{"gross_charge":12.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG CAPSULE [9499]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-152-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-637-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APRACLONIDINE 0.5 % EYE DROPS [9119]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-665-05","type":"NDC"}],"standard_charges":[{"gross_charge":122.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"UREA 15 GRAM ORAL POWDER PACKET [183854]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6253000011","type":"NDC"}],"standard_charges":[{"gross_charge":11.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-401-01","type":"NDC"}],"standard_charges":[{"gross_charge":66.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-884-01","type":"NDC"}],"standard_charges":[{"gross_charge":53.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAZOSIN 1 MG CAPSULE [6468]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-4067-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9570-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9722-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0123-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE [119007]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-8330-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [112788]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0182-01","type":"NDC"}],"standard_charges":[{"gross_charge":80.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [121353]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-31","type":"NDC"}],"standard_charges":[{"gross_charge":10.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION [4985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0301-10","type":"NDC"}],"standard_charges":[{"gross_charge":23.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-0209-22","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904052361","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6773-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET [2012]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055503200","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [207762]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-124-88","type":"NDC"}],"standard_charges":[{"gross_charge":114.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DORZOLAMIDE 2 % EYE DROPS [14471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-019-10","type":"NDC"}],"standard_charges":[{"gross_charge":69.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-186-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"73293-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":4.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACCHAROMYCES BOULARDII 250 MG CAPSULE [37343]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733380025","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-BOTOX 100 UNITS (10 UNITS/ML) IN 0.9% SODIUM CHLORIDE SYRINGE [508122]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 50 MG CAPSULE [2624]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-3141-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETAMINE 100 MG/ML INJECTION SOLUTION [4237]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9509-01","type":"NDC"}],"standard_charges":[{"gross_charge":35.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4100-90","type":"NDC"}],"standard_charges":[{"gross_charge":19.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METRONIDAZOLE 250 MG/50 ML-SODIUM CHLORIDE(ISO) [480070]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9541-24","type":"NDC"}],"standard_charges":[{"gross_charge":6648.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION [131499]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2310-01","type":"NDC"}],"standard_charges":[{"gross_charge":190.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-10","type":"NDC"}],"standard_charges":[{"gross_charge":1404.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-410-76","type":"NDC"}],"standard_charges":[{"gross_charge":7.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-394-79","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-614-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-27","type":"NDC"}],"standard_charges":[{"gross_charge":8.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 10 MG TABLET [9506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-436-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [181236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1838-1","type":"NDC"}],"standard_charges":[{"gross_charge":276.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-718-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-39","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0002-7597-01","type":"NDC"}],"standard_charges":[{"gross_charge":143.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MOXIFLOXACIN 400 MG TABLET [26854]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-7387-56","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9386-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-0445-35","type":"NDC"}],"standard_charges":[{"gross_charge":1.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4276-16","type":"NDC"}],"standard_charges":[{"gross_charge":4.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-9514-81","type":"NDC"}],"standard_charges":[{"gross_charge":25.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-5325-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7027-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION [31270]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"11994-011-16","type":"NDC"}],"standard_charges":[{"gross_charge":142.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARTIFICIAL TEAR BOTTLE WRAPPER [632222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"29943-004-10","type":"NDC"}],"standard_charges":[{"gross_charge":27.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION [9938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59676-310-00","type":"NDC"}],"standard_charges":[{"gross_charge":484.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OSELTAMIVIR 75 MG CAPSULE [26546]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-677-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70095-024-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-118-10","type":"NDC"}],"standard_charges":[{"gross_charge":51.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"72485-670-31","type":"NDC"}],"standard_charges":[{"gross_charge":24.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PREDNISONE 10 MG TABLET [6494]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0017-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0316-0231-25","type":"NDC"}],"standard_charges":[{"gross_charge":13.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":3.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION [6429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6653-18","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6027-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6057-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6231-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":22.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SIMETHICONE 80 MG CHEWABLE TABLET [7227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"24385-118-78","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-106-67","type":"NDC"}],"standard_charges":[{"gross_charge":4.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BARIUM SULFATE 60 % ORAL CREAM [96947]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"32909-770-01","type":"NDC"}],"standard_charges":[{"gross_charge":49.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":25.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION [181920]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-015-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"49348-379-54","type":"NDC"}],"standard_charges":[{"gross_charge":16.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORTHALIDONE 25 MG TABLET [1661]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-058-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2116-0","type":"NDC"}],"standard_charges":[{"gross_charge":1.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54288-166-01","type":"NDC"}],"standard_charges":[{"gross_charge":192.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VALSARTAN 40 MG TABLET [33541]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-612-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-670-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9673-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION [11403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0048-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6142-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-937-25","type":"NDC"}],"standard_charges":[{"gross_charge":30.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 88 MCG TABLET [10403]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-486-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MECLIZINE 12.5 MG TABLET [12024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-775-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION [29335]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-604-00","type":"NDC"}],"standard_charges":[{"gross_charge":27.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 400 MG CAPSULE [18307]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-984-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-502-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-351-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHAMBUTOL 400 MG TABLET [9983]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-281-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MELOXICAM 7.5 MG TABLET [20566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-050-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WHITE PETROLATUM 41 % TOPICAL OINTMENT [126146]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"7214045231","type":"NDC"}],"standard_charges":[{"gross_charge":14.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"72485-670-31","type":"NDC"}],"standard_charges":[{"gross_charge":24.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"SODIUM BICARBONATE 650 MG TABLET [7312]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733383125","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306544","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"},{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LACTASE 9,000 UNIT CHEWABLE TABLET [122812]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0045093032","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [167937]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2308-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"OR-FENTANYL-0.9% SODIUM CHLORIDE IV [440067]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9093-45","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0597-0360-82","type":"NDC"}],"standard_charges":[{"gross_charge":9.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOPIDOGREL 75 MG TABLET [22142]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6294-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-132-67","type":"NDC"}],"standard_charges":[{"gross_charge":16.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION [12748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-186-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"4116705848","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-698-11","type":"NDC"}],"standard_charges":[{"gross_charge":321.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEMANTINE 5 MG TABLET [37170]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-596-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPENTOLATE 1 % EYE DROPS [2025]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-396-01","type":"NDC"}],"standard_charges":[{"gross_charge":27.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-647-25","type":"NDC"}],"standard_charges":[{"gross_charge":105.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-012-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METHYLPHENIDATE 5 MG TABLET [4988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-805-21","type":"NDC"}],"standard_charges":[{"gross_charge":4.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG TABLET [26817]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-870-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-062-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-362-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION [130758]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0018-20","type":"NDC"}],"standard_charges":[{"gross_charge":169.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0045044406","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0092-65","type":"NDC"}],"standard_charges":[{"gross_charge":74.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [131616]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-3642-03","type":"NDC"}],"standard_charges":[{"gross_charge":489.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0947-55","type":"NDC"}],"standard_charges":[{"gross_charge":20.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35942]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5317-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0552-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1412-04","type":"NDC"}],"standard_charges":[{"gross_charge":5.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION [7028]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1966-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6727-23","type":"NDC"}],"standard_charges":[{"gross_charge":15.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML INJECTION SOLUTION [125938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-168-01","type":"NDC"}],"standard_charges":[{"gross_charge":471.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [189176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-620-01","type":"NDC"}],"standard_charges":[{"gross_charge":21.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-204-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-405-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-089-50","type":"NDC"}],"standard_charges":[{"gross_charge":16.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-22","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-49","type":"NDC"}],"standard_charges":[{"gross_charge":15.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [29302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0759-08","type":"NDC"}],"standard_charges":[{"gross_charge":108.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY [19696]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0283-0679-02","type":"NDC"}],"standard_charges":[{"gross_charge":84.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1559-30","type":"NDC"}],"standard_charges":[{"gross_charge":12.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9094-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6001-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-473-32","type":"NDC"}],"standard_charges":[{"gross_charge":3.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 81 % (W/W) ORAL POWDER [99696]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"32909-105-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":28.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-299-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-168-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION [18877]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-252-40","type":"NDC"}],"standard_charges":[{"gross_charge":27.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [129705]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-275-62","type":"NDC"}],"standard_charges":[{"gross_charge":9.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-660-05","type":"NDC"}],"standard_charges":[{"gross_charge":4.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZIPRASIDONE 20 MG CAPSULE [29778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-988-32","type":"NDC"}],"standard_charges":[{"gross_charge":5.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68308-505-47","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [14983]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-5000-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0945-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9875-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4100-90","type":"NDC"}],"standard_charges":[{"gross_charge":19.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 2 GRAM/100 ML IN DEXTROSE(ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [175908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3508-41","type":"NDC"}],"standard_charges":[{"gross_charge":27.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0469-6501-89","type":"NDC"}],"standard_charges":[{"gross_charge":714.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 25 MG TABLET [15748]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6303-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27241-115-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":27.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-300-90","type":"NDC"}],"standard_charges":[{"gross_charge":176.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-752-78","type":"NDC"}],"standard_charges":[{"gross_charge":266.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENOFIBRATE 54 MG TABLET [31336]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-312-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"61269-735-14","type":"NDC"}],"standard_charges":[{"gross_charge":5.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-51","type":"NDC"}],"standard_charges":[{"gross_charge":40.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-27","type":"NDC"}],"standard_charges":[{"gross_charge":15.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-368-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [24559]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733394825","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"79672-613-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-0277-31","type":"NDC"}],"standard_charges":[{"gross_charge":30.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREGABALIN 25 MG CAPSULE [42162]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-1012-68","type":"NDC"}],"standard_charges":[{"gross_charge":28.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BENZTROPINE 1 MG TABLET [999]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-2438-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-9273-80","type":"NDC"}],"standard_charges":[{"gross_charge":68.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIVALPROEX 125 MG TABLET,DELAYED RELEASE [2551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-7122-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMMONIUM LACTATE 12 % TOPICAL CREAM [17997]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904598348","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6794-80","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7127-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 100 MG CAPSULE [18309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-661-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOCONAZOLE 2 % TOPICAL CREAM [10368]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1298-1","type":"NDC"}],"standard_charges":[{"gross_charge":18.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55566-2800-1","type":"NDC"}],"standard_charges":[{"gross_charge":1396.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 10 MG TABLET [6494]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-134-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2552]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-868-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINERAL OIL [94447]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6332325410","type":"NDC"}],"standard_charges":[{"gross_charge":26.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67850-041-00","type":"NDC"}],"standard_charges":[{"gross_charge":12.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESTRADIOL 1 MG TABLET [9967]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-565-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC OXIDE 20 % TOPICAL OINTMENT [8874]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"75834-170-02","type":"NDC"}],"standard_charges":[{"gross_charge":23.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1744-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE FUR. 200 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER [194467]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0893-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9801-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536440601","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 80 MG CHEWABLE TABLET [7227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5068-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE [128663]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-636-03","type":"NDC"}],"standard_charges":[{"gross_charge":225.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42291-184-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [29302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42799-815-01","type":"NDC"}],"standard_charges":[{"gross_charge":102.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SOTALOL 120 MG TABLET [15723]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-725-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-167-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":51.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 3,000 UNIT/ML INJECTION SOLUTION [9940]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-267-01","type":"NDC"}],"standard_charges":[{"gross_charge":142.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 0.3 % EYE DROPS [3428]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-633-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-445-12","type":"NDC"}],"standard_charges":[{"gross_charge":6.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRTAZAPINE 7.5 MG TABLET [38421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66993-606-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION [30479]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-123-59","type":"NDC"}],"standard_charges":[{"gross_charge":15.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733398325","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORTRIPTYLINE 25 MG CAPSULE [5675]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-0811-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [165023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9525-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 % MUCOSAL SPRAY [27666]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0283-0610-11","type":"NDC"}],"standard_charges":[{"gross_charge":66.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION [119843]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1412-50","type":"NDC"}],"standard_charges":[{"gross_charge":337.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLUCAGON HCL 1 MG/ML INJECTION WRAPPER [339421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0548-5850-00","type":"NDC"}],"standard_charges":[{"gross_charge":526.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFPODOXIME 200 MG TABLET [9469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-5439-20","type":"NDC"}],"standard_charges":[{"gross_charge":15.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6730-80","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7035-88","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [19436]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"32909-764-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE (VITAMIN B1) 100 MG TABLET (WRAPPER) [508008]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"3786490501","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-167-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"PROCHLORPERAZINE MALEATE 10 MG TABLET [6582]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-825-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-487-07","type":"NDC"}],"standard_charges":[{"gross_charge":32.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-187-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SELEXIPAG 600 MCG TABLET [177923]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66215-606-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-583-40","type":"NDC"}],"standard_charges":[{"gross_charge":77.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72205-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-4184-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [28282]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0088-2220-33","type":"NDC"}],"standard_charges":[{"gross_charge":170.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9622-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11076]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0705-48","type":"NDC"}],"standard_charges":[{"gross_charge":8.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [28408]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-3350-16","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-71","type":"NDC"}],"standard_charges":[{"gross_charge":27.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 25 MG TABLET [3774]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6617-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6761-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-131-82","type":"NDC"}],"standard_charges":[{"gross_charge":5.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-001-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [190478]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-132-01","type":"NDC"}],"standard_charges":[{"gross_charge":5181.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-579-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TIMOLOL MALEATE 0.25 % EYE DROPS [11561]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-226-05","type":"NDC"}],"standard_charges":[{"gross_charge":7.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-376-04","type":"NDC"}],"standard_charges":[{"gross_charge":7.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-421-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-004-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9622-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-38","type":"NDC"}],"standard_charges":[{"gross_charge":4.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLYCERIN 99.5 % TOPICAL SOLUTION [82033]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0395-1031-96","type":"NDC"}],"standard_charges":[{"gross_charge":18.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9093-37","type":"NDC"}],"standard_charges":[{"gross_charge":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [82301]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-115-04","type":"NDC"}],"standard_charges":[{"gross_charge":5.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-041-63","type":"NDC"}],"standard_charges":[{"gross_charge":389.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE 10MCG/ML ORAL SUSPENSION [975044]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-299-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55111-678-11","type":"NDC"}],"standard_charges":[{"gross_charge":26.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [124737]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57664-683-31","type":"NDC"}],"standard_charges":[{"gross_charge":69.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6068783445","type":"NDC"}],"standard_charges":[{"gross_charge":7.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-878-42","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3339-1","type":"NDC"}],"standard_charges":[{"gross_charge":24.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [187312]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83257-005-41","type":"NDC"}],"standard_charges":[{"gross_charge":5116.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 750 MG/150 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [108740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-38","type":"NDC"}],"standard_charges":[{"gross_charge":149.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC 99M-LABELED RED BLOOD CELLS [40840062]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9003-74","type":"NDC"}],"standard_charges":[{"gross_charge":900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"WARFARIN 1 MG TABLET [11664]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-1712-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9333-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION [172739]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0874-10","type":"NDC"}],"standard_charges":[{"gross_charge":360.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 3 % IV BOLUS [450284]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7805-10","type":"NDC"}],"standard_charges":[{"gross_charge":17.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1202-29","type":"NDC"}],"standard_charges":[{"gross_charge":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0832-6032-12","type":"NDC"}],"standard_charges":[{"gross_charge":261.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG TABLET [17937]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6376-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-622-31","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET [11218]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"37000-024-04","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-116-25","type":"NDC"}],"standard_charges":[{"gross_charge":4.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE [5595]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-623-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [127611]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6143-0","type":"NDC"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SERTRALINE 25 MG TABLET [19882]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-231-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [165400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-415-10","type":"NDC"}],"standard_charges":[{"gross_charge":77.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CALCIUM POLYCARBOPHIL 625 MG TABLET [11046]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"77333-120-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8452176708","type":"NDC"}],"standard_charges":[{"gross_charge":3.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-22","type":"NDC"}],"standard_charges":[{"gross_charge":2.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8215-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TEMAZEPAM 15 MG CAPSULE [7753]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2076-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE [12184]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5317-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-65","type":"NDC"}],"standard_charges":[{"gross_charge":0.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [167937]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2308-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3375-14","type":"NDC"}],"standard_charges":[{"gross_charge":7.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":29.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 3 % FOR NEBULIZATION [7327]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487900330","type":"NDC"}],"standard_charges":[{"gross_charge":1.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9501-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6059-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CEPHALEXIN 250 MG CAPSULE [9499]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-151-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-600-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MEXILETINE 150 MG CAPSULE [10595]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-239-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-186-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-560-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-494-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71399-8245-3","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCRALFATE 1 GRAM TABLET [11442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-2210-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-KETAMINE-0.9% SODIUM CHLORIDE IV [440066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9509-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [183738]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0310-4611-50","type":"NDC"}],"standard_charges":[{"gross_charge":12164.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LAMOTRIGINE 100 MG TABLET [13982]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7008-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLN (BELRAPZO) [606226]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42367-521-25","type":"NDC"}],"standard_charges":[{"gross_charge":6296.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-211-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"HALOPERIDOL 1 MG TABLET [3579]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-734-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [192838]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55135-132-01","type":"NDC"}],"standard_charges":[{"gross_charge":7255.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE [108044]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-025-01","type":"NDC"}],"standard_charges":[{"gross_charge":1007.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-185-08","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [106363]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-491-57","type":"NDC"}],"standard_charges":[{"gross_charge":218.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARISOPRODOL 350 MG TABLET [1395]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-049-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION [37989]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66733-958-23","type":"NDC"}],"standard_charges":[{"gross_charge":4583.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE [10455]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-655-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TROPICAMIDE 1 % EYE DROPS [8250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-121-01","type":"NDC"}],"standard_charges":[{"gross_charge":20.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70700-268-94","type":"NDC"}],"standard_charges":[{"gross_charge":160.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-435-91","type":"NDC"}],"standard_charges":[{"gross_charge":12.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0132-0079-24","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-5164-15","type":"NDC"}],"standard_charges":[{"gross_charge":120.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1162-19","type":"NDC"}],"standard_charges":[{"gross_charge":5.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-16","type":"NDC"}],"standard_charges":[{"gross_charge":7.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [121353]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-50","type":"NDC"}],"standard_charges":[{"gross_charge":20.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0031-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7924-09","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE [128663]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-636-30","type":"NDC"}],"standard_charges":[{"gross_charge":225.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-101-67","type":"NDC"}],"standard_charges":[{"gross_charge":2.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-164-01","type":"NDC"}],"standard_charges":[{"gross_charge":224.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-505-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 2 MG TABLET [2404]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-284-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-836-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-406-03","type":"NDC"}],"standard_charges":[{"gross_charge":21.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88376]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-252-01","type":"NDC"}],"standard_charges":[{"gross_charge":69.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-507-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFADROXIL 500 MG CAPSULE [9436]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3196-53","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION [11403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0047-47","type":"NDC"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":3.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0395-2325-16","type":"NDC"}],"standard_charges":[{"gross_charge":165.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-08","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [121784]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-1410-31","type":"NDC"}],"standard_charges":[{"gross_charge":15.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3232-94","type":"NDC"}],"standard_charges":[{"gross_charge":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"HYDRALAZINE 25 MG TABLET [3700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6441-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-900-99","type":"NDC"}],"standard_charges":[{"gross_charge":0.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":24.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"ARGATROBAN 50 MG/50 ML (1 MG/ML) WRAPPER [508177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-414-50","type":"NDC"}],"standard_charges":[{"gross_charge":145.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-438-92","type":"NDC"}],"standard_charges":[{"gross_charge":4182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS [127977]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50289-3250-1","type":"NDC"}],"standard_charges":[{"gross_charge":7.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-177-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MECLIZINE 12.5 MG TABLET [12024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-775-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION [16169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-418-01","type":"NDC"}],"standard_charges":[{"gross_charge":749.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIVOLUMAB 120 MG/12 ML INTRAVENOUS SOLUTION [197401]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-3756-14","type":"NDC"}],"standard_charges":[{"gross_charge":11272.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0013-1114-20","type":"NDC"}],"standard_charges":[{"gross_charge":12.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOTREXATE SODIUM 2.5 MG TABLET [4973]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8550-25","type":"NDC"}],"standard_charges":[{"gross_charge":8.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-7415-51","type":"NDC"}],"standard_charges":[{"gross_charge":2.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"URSODIOL 300 MG CAPSULE [11624]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-3159-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-730-06","type":"NDC"}],"standard_charges":[{"gross_charge":82.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [121241]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"48433-230-15","type":"NDC"}],"standard_charges":[{"gross_charge":94.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2116-4","type":"NDC"}],"standard_charges":[{"gross_charge":1.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-044-00","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-652-10","type":"NDC"}],"standard_charges":[{"gross_charge":43.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 1 MG/ML INJECTION SOLUTION [121831]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-852-03","type":"NDC"}],"standard_charges":[{"gross_charge":8.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-594-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL 4 MG TABLET [10778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-220-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TAMSULOSIN 0.4 MG CAPSULE [103890]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-299-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3340-1","type":"NDC"}],"standard_charges":[{"gross_charge":30.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-99","type":"NDC"}],"standard_charges":[{"gross_charge":1039.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-TRANEXEMIC ACID INFUSION 3,000 MG/250 ML IN NS [975035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81284-611-00","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TECHNETIUM TC-99M SULFUR COLLOID [40840061]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9003-69","type":"NDC"}],"standard_charges":[{"gross_charge":153.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [130944]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0011-03","type":"NDC"}],"standard_charges":[{"gross_charge":65.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9785-01","type":"NDC"}],"standard_charges":[{"gross_charge":45.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 2 GRAM/100 ML IN DEXTROSE(ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [175908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3508-41","type":"NDC"}],"standard_charges":[{"gross_charge":27.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1414-60","type":"NDC"}],"standard_charges":[{"gross_charge":28.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN B COMPLEX CAPSULE [804]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536137801","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-415-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-116-20","type":"NDC"}],"standard_charges":[{"gross_charge":5.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"BUPROPION HCL 75 MG TABLET [9322]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-0158-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LOPERAMIDE 2 MG CAPSULE [4560]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-229-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-78","type":"NDC"}],"standard_charges":[{"gross_charge":28.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-390-54","type":"NDC"}],"standard_charges":[{"gross_charge":20.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [125727]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-477-45","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-494-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARISOPRODOL 350 MG TABLET [1395]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69584-111-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-510-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [17405]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-7510-17","type":"NDC"}],"standard_charges":[{"gross_charge":40.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALPROSTADIL 500 MCG/ML INJECTION SOLUTION [9001]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3169-01","type":"NDC"}],"standard_charges":[{"gross_charge":390.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK [198215]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-5045-06","type":"NDC"}],"standard_charges":[{"gross_charge":414.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORTHALIDONE 25 MG TABLET [1661]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0222-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 180 MG IODINE/ML INTRATHECAL SOLUTION [10319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1411-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-16","type":"NDC"}],"standard_charges":[{"gross_charge":7.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7214-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-0493-03","type":"NDC"}],"standard_charges":[{"gross_charge":47.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":24.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [129971]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-673-77","type":"NDC"}],"standard_charges":[{"gross_charge":15.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-420-00","type":"NDC"}],"standard_charges":[{"gross_charge":18.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETIC ACID (BULK) 5 % LIQUID [14702]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5155200556","type":"NDC"}],"standard_charges":[{"gross_charge":175.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-595-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOPROLOL TARTRATE 25 MG TABLET [37637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-265-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-07","type":"NDC"}],"standard_charges":[{"gross_charge":32.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-423-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATORVASTATIN 40 MG TABLET [19177]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-099-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70700-268-99","type":"NDC"}],"standard_charges":[{"gross_charge":146.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-700-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [28018]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0315-08","type":"NDC"}],"standard_charges":[{"gross_charge":17.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4400-54","type":"NDC"}],"standard_charges":[{"gross_charge":8.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [11081]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0691-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0512-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-25","type":"NDC"}],"standard_charges":[{"gross_charge":13.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTASE 9,000 UNIT TABLET [122091]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904590887","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [129417]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904-6488-38","type":"NDC"}],"standard_charges":[{"gross_charge":11.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXCARBAZEPINE 150 MG TABLET [27049]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7262-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-591-81","type":"NDC"}],"standard_charges":[{"gross_charge":179.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-748-76","type":"NDC"}],"standard_charges":[{"gross_charge":4.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDODRINE 2.5 MG TABLET [10609]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-561-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM ER 120 MG CAPSULE,EXTENDED RELEASE 12 HR [11892]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-926-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51754-5001-1","type":"NDC"}],"standard_charges":[{"gross_charge":15.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION [9941]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59676-304-00","type":"NDC"}],"standard_charges":[{"gross_charge":294.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYALURONATE SODIUM, STABILIZED 88 MG/4 ML INTRA-ARTICULAR SYRINGE [169356]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5967682001","type":"NDC"}],"standard_charges":[{"gross_charge":4275.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION [3208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60758-880-05","type":"NDC"}],"standard_charges":[{"gross_charge":191.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-507-25","type":"NDC"}],"standard_charges":[{"gross_charge":15.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1573-1","type":"NDC"}],"standard_charges":[{"gross_charge":12.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-434-84","type":"NDC"}],"standard_charges":[{"gross_charge":9.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BALSALAZIDE 750 MG CAPSULE [29299]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0079-28","type":"NDC"}],"standard_charges":[{"gross_charge":2.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9251-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IODIXANOL 270 MG IODINE/ML INTRAVENOUS SOLUTION [17594]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-2222-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6014-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3491-94","type":"NDC"}],"standard_charges":[{"gross_charge":52.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6730-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-106-67","type":"NDC"}],"standard_charges":[{"gross_charge":4.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-420-24","type":"NDC"}],"standard_charges":[{"gross_charge":18.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [207762]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-124-65","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-173-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"SOTALOL 80 MG TABLET [11421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-0080-0","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEDROXYPROGESTERONE 10 MG TABLET [4854]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-105-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GEMFIBROZIL 600 MG TABLET [3378]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-224-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"61570-131-25","type":"NDC"}],"standard_charges":[{"gross_charge":14.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [106364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-462-37","type":"NDC"}],"standard_charges":[{"gross_charge":36.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-056-99","type":"NDC"}],"standard_charges":[{"gross_charge":4.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-436-88","type":"NDC"}],"standard_charges":[{"gross_charge":15.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"81284-152-00","type":"NDC"}],"standard_charges":[{"gross_charge":8.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-BOTOX 100 UNITS (10 UNITS/ML) IN 0.9% SODIUM CHLORIDE SYRINGE [508122]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0087074002","type":"NDC"}],"standard_charges":[{"gross_charge":154.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3425-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1971-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALACYCLOVIR 500 MG TABLET [13133]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-4275-93","type":"NDC"}],"standard_charges":[{"gross_charge":1.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPHENIDATE ER 54 MG TABLET,EXTENDED RELEASE 24 HR [29388]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-8158-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4602-25","type":"NDC"}],"standard_charges":[{"gross_charge":8.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6132-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERITONEAL DIALYSIS SOLN 6 (DIANEAL) DEXTR 1.5%-CA 2.5 MEQ/L-MG 0.5 MEQ/L [27796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0424-52","type":"NDC"}],"standard_charges":[{"gross_charge":78.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-345-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-438-20","type":"NDC"}],"standard_charges":[{"gross_charge":4182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [130190]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-249-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALSARTAN 80 MG TABLET [31209]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-623-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PILOCARPINE 2 % EYE DROPS [6280]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-204-15","type":"NDC"}],"standard_charges":[{"gross_charge":186.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINERAL OIL, LIGHT STERILE [191645]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6332325402","type":"NDC"}],"standard_charges":[{"gross_charge":23.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CINACALCET 30 MG TABLET [38100]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-831-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-354-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-5100-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRTAZAPINE 7.5 MG TABLET [38421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"9999-9999-46","type":"NDC"}],"standard_charges":[{"gross_charge":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0049-0530-28","type":"NDC"}],"standard_charges":[{"gross_charge":76.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9386-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"ASPIRIN 325 MG TABLET,DELAYED RELEASE [685]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1232-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERITONEAL DIALYSIS SOLN 8 (DIANEAL) DEXTR 4.25%-CA 2.5 MEQ/L-MG 0.5 MEQ/L [27804]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0433-52","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL JELLY [4448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-711-30","type":"NDC"}],"standard_charges":[{"gross_charge":15.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"29300-415-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION [9080]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-204-51","type":"NDC"}],"standard_charges":[{"gross_charge":136.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-044-13","type":"NDC"}],"standard_charges":[{"gross_charge":12738.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026885911","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-710-01","type":"NDC"}],"standard_charges":[{"gross_charge":5027.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SEVELAMER CARBONATE 800 MG TABLET [89201]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"58468-0130-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [28643]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62175-260-37","type":"NDC"}],"standard_charges":[{"gross_charge":2.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-294-07","type":"NDC"}],"standard_charges":[{"gross_charge":2.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68682-993-98","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET [1760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-158-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-TRANEXEMIC ACID INFUSION 3,000 MG/250 ML IN NS [975035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-510-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72888-106-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3073-03","type":"NDC"}],"standard_charges":[{"gross_charge":15.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0046-0872-21","type":"NDC"}],"standard_charges":[{"gross_charge":1246.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [187730]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0310-1110-01","type":"NDC"}],"standard_charges":[{"gross_charge":59.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1631-10","type":"NDC"}],"standard_charges":[{"gross_charge":34.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-BUPIVACAINE-EPI/LIDOCAINE-EPI 0.5%-1:200,000 [440051]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-1020-25","type":"NDC"}],"standard_charges":[{"gross_charge":73.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6022-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ATROPINE 1 % EYE DROPS [736]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-215-05","type":"NDC"}],"standard_charges":[{"gross_charge":143.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENTACAPONE 200 MG TABLET [26547]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-273-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FIDAXOMICIN 200 MG TABLET [110360]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"52015-080-01","type":"NDC"}],"standard_charges":[{"gross_charge":350.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 10 MG TABLET [11110]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-229-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-194-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WHITE PETROLATUM TOPICAL OINTMENT IN PACKET [132649]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"57896-114-14","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-29","type":"NDC"}],"standard_charges":[{"gross_charge":5.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-65","type":"NDC"}],"standard_charges":[{"gross_charge":30.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-376-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APIXABAN 2.5 MG TABLET [119040]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-0893-31","type":"NDC"}],"standard_charges":[{"gross_charge":20.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-0623-00","type":"NDC"}],"standard_charges":[{"gross_charge":68.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9924-90","type":"NDC"}],"standard_charges":[{"gross_charge":3.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT [8118]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0006-15","type":"NDC"}],"standard_charges":[{"gross_charge":7.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1202-07","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10135-620-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14362-0111-3","type":"NDC"}],"standard_charges":[{"gross_charge":55.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PENICILLIN V POTASSIUM 250 MG TABLET [6092]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-234-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCHLOROTHIAZIDE 25 MG TABLET [3720]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-183-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-007-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED RELEASE [38225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-226-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 50 MG TABLET [5009]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-266-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-286-31","type":"NDC"}],"standard_charges":[{"gross_charge":22.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [39918]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-306-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68001-525-27","type":"NDC"}],"standard_charges":[{"gross_charge":71.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69374-946-04","type":"NDC"}],"standard_charges":[{"gross_charge":19.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-411-80","type":"NDC"}],"standard_charges":[{"gross_charge":19.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-93","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132-0201-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1778-15","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10%-SODIUM CHLORIDE 10 MEQ-POTASSIUM CHLORIDE 5 MEQ INTRAVENOUS SOLUTION (NEONATAL) [975064]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7107-09","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIOTHYRONINE 5 MCG TABLET [10443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0574-0220-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7093-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-01","type":"NDC"}],"standard_charges":[{"gross_charge":30.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LISINOPRIL 10 MG TABLET [10449]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-416-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-547-58","type":"NDC"}],"standard_charges":[{"gross_charge":33.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51754-0203-2","type":"NDC"}],"standard_charges":[{"gross_charge":19.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-423-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-567-00","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69918-899-01","type":"NDC"}],"standard_charges":[{"gross_charge":170.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-600-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-401-41","type":"NDC"}],"standard_charges":[{"gross_charge":14.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132-0201-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0089-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9094-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6105-25","type":"NDC"}],"standard_charges":[{"gross_charge":98.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6125-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"CARBIDOPA 37.5 MG-LEVODOPA 150 MG-ENTACAPONE 200 MG TABLET [36137]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-5654-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11076]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7075-26","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"31722-306-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MISOPROSTOL 200 MCG TABLET [10629]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43386-161-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-438-92","type":"NDC"}],"standard_charges":[{"gross_charge":4182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREDNISOLONE 15 MG/5 ML ORAL SOLUTION [11117]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-042-48","type":"NDC"}],"standard_charges":[{"gross_charge":151.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [113477]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-248-47","type":"NDC"}],"standard_charges":[{"gross_charge":109.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLPIDEM 5 MG TABLET [11701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-838-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-125-94","type":"NDC"}],"standard_charges":[{"gross_charge":54.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-27","type":"NDC"}],"standard_charges":[{"gross_charge":14.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-665-01","type":"NDC"}],"standard_charges":[{"gross_charge":54.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-339-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76204-600-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"TECHNETIUM TC 99M-WHITE BLOOD CELLS [405010]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-4001-05","type":"NDC"}],"standard_charges":[{"gross_charge":5100.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8315-17","type":"NDC"}],"standard_charges":[{"gross_charge":41.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1159-18","type":"NDC"}],"standard_charges":[{"gross_charge":5.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TOPIRAMATE 25 MG TABLET [18920]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6928-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERMETHRIN 5 % TOPICAL CREAM [10917]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"21922-021-07","type":"NDC"}],"standard_charges":[{"gross_charge":41.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-192-87","type":"NDC"}],"standard_charges":[{"gross_charge":19.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"45802-410-59","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROSUVASTATIN 40 MG TABLET [35136]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-171-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 0.5 MG TABLET [9637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-544-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 300 MG TABLET [311]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-688-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PRAVASTATIN 10 MG TABLET [11110]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-886-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 0.2 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN [130864]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61553-890-48","type":"NDC"}],"standard_charges":[{"gross_charge":87.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-411-12","type":"NDC"}],"standard_charges":[{"gross_charge":3.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-599-62","type":"NDC"}],"standard_charges":[{"gross_charge":2.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-725-01","type":"NDC"}],"standard_charges":[{"gross_charge":792.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLUCOSE CHEWABLE TABLET 3.75 G (TOT 4 G CHO) [210838]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8068110000","type":"NDC"}],"standard_charges":[{"gross_charge":0.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 40 MG TABLET [3295]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8299-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-18","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5921-01","type":"NDC"}],"standard_charges":[{"gross_charge":46.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9904-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MONTELUKAST 10 MG TABLET [22509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6529-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6794-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"HYDRALAZINE 50 MG TABLET [3701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"23155-834-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAMOXINE 1 % TOPICAL FOAM [19749]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51862-180-15","type":"NDC"}],"standard_charges":[{"gross_charge":135.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [132172]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54643-5649-1","type":"NDC"}],"standard_charges":[{"gross_charge":28.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CROMOLYN 4 % EYE DROPS [9691]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-237-10","type":"NDC"}],"standard_charges":[{"gross_charge":14.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-367-11","type":"NDC"}],"standard_charges":[{"gross_charge":14.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-016-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 25 MG TABLET [15748]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-095-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-720-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69097-614-37","type":"NDC"}],"standard_charges":[{"gross_charge":121.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-904-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [27490]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69367-265-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [181236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"9999-4007-03","type":"NDC"}],"standard_charges":[{"gross_charge":24.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [28018]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0315-08","type":"NDC"}],"standard_charges":[{"gross_charge":17.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMLODIPINE 5 MG TABLET [9071]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-1530-68","type":"NDC"}],"standard_charges":[{"gross_charge":23.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121119030","type":"NDC"}],"standard_charges":[{"gross_charge":11.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET [94158]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0223-1760-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION [27735]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-0149-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-38","type":"NDC"}],"standard_charges":[{"gross_charge":2.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1778-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRIMIDONE 250 MG TABLET [6544]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-1231-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PSEUDOEPHEDRINE 30 MG TABLET [6714]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6990-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUDEOXYGLUCOSE F-18 20 MCI TO 300 MCI/ML INTRAVENOUS SOLUTION [166036]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13267-123-23","type":"NDC"}],"standard_charges":[{"gross_charge":353.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [207761]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"19515-810-52","type":"NDC"}],"standard_charges":[{"gross_charge":45.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FERROUS GLUCONATE 324 MG TABLET WRAPPER [421037]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055501900","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-447-71","type":"NDC"}],"standard_charges":[{"gross_charge":3.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM [9175]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1310-1","type":"NDC"}],"standard_charges":[{"gross_charge":7.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [190450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-207-01","type":"NDC"}],"standard_charges":[{"gross_charge":5188.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-718-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORTRIPTYLINE 25 MG CAPSULE [5675]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75907-070-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0008-0923-51","type":"NDC"}],"standard_charges":[{"gross_charge":5.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [187242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1308-01","type":"NDC"}],"standard_charges":[{"gross_charge":272.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0067-01","type":"NDC"}],"standard_charges":[{"gross_charge":2788.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1709-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE 0.125% EPIDURAL [400818]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1165-02","type":"NDC"}],"standard_charges":[{"gross_charge":10.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3290-09","type":"NDC"}],"standard_charges":[{"gross_charge":12.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-705-87","type":"NDC"}],"standard_charges":[{"gross_charge":24.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50383-924-93","type":"NDC"}],"standard_charges":[{"gross_charge":2.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-991-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2115-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-207-20","type":"NDC"}],"standard_charges":[{"gross_charge":4.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 1 % EYE DROPS [736]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6226-1","type":"NDC"}],"standard_charges":[{"gross_charge":86.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-619-10","type":"NDC"}],"standard_charges":[{"gross_charge":180.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-246-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70095-025-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-403-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-808-77","type":"NDC"}],"standard_charges":[{"gross_charge":27.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8215-17","type":"NDC"}],"standard_charges":[{"gross_charge":7.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION WRAPPER [425002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9331-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 20 MG/ML IV SYRINGE IN DEXTROSE (FROM ISO-OSMOTIC PREMIX) (PEDIATRIC) [777139]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3503-41","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION WRAPPER [978722]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-50","type":"NDC"}],"standard_charges":[{"gross_charge":20.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0720-01","type":"NDC"}],"standard_charges":[{"gross_charge":102.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6730-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TORSEMIDE 20 MG TABLET [18293]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7283-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED RELEASE [38225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51991-818-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAPTOPRIL 25 MG TABLET [9402]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-315-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 200 MG TABLET [10374]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-450-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-064-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-09","type":"NDC"}],"standard_charges":[{"gross_charge":8.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERPHENAZINE 4 MG TABLET [6158]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-602-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-808-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-167-50","type":"NDC"}],"standard_charges":[{"gross_charge":415.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INHALATIONAL SPACING DEVICE WITH MEDIUM MASK [187722]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8373982600","type":"NDC"}],"standard_charges":[{"gross_charge":47.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE(PF) 0.2 %-0.9 % SODCHL 545 ML INFIL,HI VAR RATE ELAST PUMP [188549]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4100-64","type":"NDC"}],"standard_charges":[{"gross_charge":990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 6 MG/ML ORAL SUSPENSION [110998]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0004-0822-05","type":"NDC"}],"standard_charges":[{"gross_charge":461.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3073-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLECAINIDE 50 MG TABLET [10043]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0010-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [9502]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-4177-73","type":"NDC"}],"standard_charges":[{"gross_charge":31.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-71","type":"NDC"}],"standard_charges":[{"gross_charge":27.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9558-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-3029-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 40 MG TABLET [11112]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5893-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6794-80","type":"NDC"}],"standard_charges":[{"gross_charge":0.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-298-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-439-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.5 MG TABLET [9309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42799-119-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-168-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE HCL 0.1 MG TABLET [1755]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-054-31","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-013-02","type":"NDC"}],"standard_charges":[{"gross_charge":13.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-36","type":"NDC"}],"standard_charges":[{"gross_charge":4.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-271-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"GLUCOSE CHEWABLE TABLET 4 G (TOT 4 G CHO) [16050]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8068110000","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION [100509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-3921-02","type":"NDC"}],"standard_charges":[{"gross_charge":3876.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [193493]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0087040203","type":"NDC"}],"standard_charges":[{"gross_charge":27.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9250-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1560-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [167938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6001-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [119246]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-801-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-241-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-059-35","type":"NDC"}],"standard_charges":[{"gross_charge":38.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-795-16","type":"NDC"}],"standard_charges":[{"gross_charge":17.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6025800601","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [180351]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-556-33","type":"NDC"}],"standard_charges":[{"gross_charge":12.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-77","type":"NDC"}],"standard_charges":[{"gross_charge":13.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-481-48","type":"NDC"}],"standard_charges":[{"gross_charge":3.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-136-02","type":"NDC"}],"standard_charges":[{"gross_charge":61.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 200 MCG TABLET [10629]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-444-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76014-004-33","type":"NDC"}],"standard_charges":[{"gross_charge":121.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [194665]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1311-01","type":"NDC"}],"standard_charges":[{"gross_charge":544.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-3641-03","type":"NDC"}],"standard_charges":[{"gross_charge":4250.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION [91054]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9701-01","type":"NDC"}],"standard_charges":[{"gross_charge":38.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METRONIDAZOLE IVPB 5 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0152-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7391-72","type":"NDC"}],"standard_charges":[{"gross_charge":41.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0477-21","type":"NDC"}],"standard_charges":[{"gross_charge":149.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3159-72","type":"NDC"}],"standard_charges":[{"gross_charge":71.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR 400 MG TABLET [8971]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5790-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-01","type":"NDC"}],"standard_charges":[{"gross_charge":1363.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [125727]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-060-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-600-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"53329-170-79","type":"NDC"}],"standard_charges":[{"gross_charge":17.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-254-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EZETIMIBE 10 MG TABLET [34153]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-052-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SPIRONOLACTONE 25 MG TABLET [7437]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-465-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HUMAN PROTHROMBIN COMPLEX (BALFAXAR) CONCENTRATE-LANS 500 UNIT IV SOLUTION [203925]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68982-261-81","type":"NDC"}],"standard_charges":[{"gross_charge":1989.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0049-0014-81","type":"NDC"}],"standard_charges":[{"gross_charge":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 50 MG CAPSULE [2624]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-3141-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3182-02","type":"NDC"}],"standard_charges":[{"gross_charge":14.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-05","type":"NDC"}],"standard_charges":[{"gross_charge":2062.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10135-111-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT [8118]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1284-1","type":"NDC"}],"standard_charges":[{"gross_charge":4.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"GABAPENTIN 400 MG CAPSULE [18307]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-602-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-743-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 25 MG TABLET [3700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-822-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-652-10","type":"NDC"}],"standard_charges":[{"gross_charge":46.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-503-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"66993-079-96","type":"NDC"}],"standard_charges":[{"gross_charge":439.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [131067]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70004-810-12","type":"NDC"}],"standard_charges":[{"gross_charge":18.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-600-41","type":"NDC"}],"standard_charges":[{"gross_charge":0.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306553","type":"NDC"}],"standard_charges":[{"gross_charge":2.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.5 MG/5 ML (100 MCG/ML)IN 0.9 % SOD.CHLORIDE IV SYRINGE [130890]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-17","type":"NDC"}],"standard_charges":[{"gross_charge":30.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [196862]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0005-2000-02","type":"NDC"}],"standard_charges":[{"gross_charge":669.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-5517-98","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":3.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1303-75","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMLODIPINE 5 MG TABLET [9071]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6370-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0955-1006-10","type":"NDC"}],"standard_charges":[{"gross_charge":35.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [207761]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"19515-810-41","type":"NDC"}],"standard_charges":[{"gross_charge":44.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENTACAPONE 200 MG TABLET [26547]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"33342-260-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-437-10","type":"NDC"}],"standard_charges":[{"gross_charge":2091.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMOTRIGINE 25 MG TABLET [13981]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-4130-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 10 MG TABLET [5005]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-631-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METHOTREXATE (ECTOPIC PREGNANCY) IM INJECTION [505009]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-350-37","type":"NDC"}],"standard_charges":[{"gross_charge":13.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 1 MG/ML INJECTION SOLUTION [121831]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-852-03","type":"NDC"}],"standard_charges":[{"gross_charge":8.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VORTIOXETINE 5 MG TABLET [166041]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64764-720-30","type":"NDC"}],"standard_charges":[{"gross_charge":47.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE [38062]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-426-12","type":"NDC"}],"standard_charges":[{"gross_charge":0.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 3.125 MG TABLET [18551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-153-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOPIRAMATE 25 MG TABLET [18920]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-342-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK [10900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1025-41","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9904-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0720-01","type":"NDC"}],"standard_charges":[{"gross_charge":102.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6022-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6194-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-9273-80","type":"NDC"}],"standard_charges":[{"gross_charge":68.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SOD BICARB-CITRIC AC-SIMETH 2.21 GRAM-1.53 GRAM/4 GRAM GRANULES EFFERV [97293]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10361-793-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-608-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-164-01","type":"NDC"}],"standard_charges":[{"gross_charge":224.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"QUETIAPINE 25 MG TABLET [21823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-327-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-794-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPINIROLE 4 MG TABLET [26429]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-035-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [169631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63824-008-34","type":"NDC"}],"standard_charges":[{"gross_charge":1.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-163-02","type":"NDC"}],"standard_charges":[{"gross_charge":182.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [28643]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-597-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-808-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 80 MG CHEWABLE TABLET [7227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69618-033-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-783-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"7139974805","type":"NDC"}],"standard_charges":[{"gross_charge":153.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS IV BOLUS [400296]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAT EMULSION 20 % INTRAVENOUS (W/CONTEXTS) [339140]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0519-09","type":"NDC"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1708-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-54","type":"NDC"}],"standard_charges":[{"gross_charge":24.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION WRAPPER [978722]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-31","type":"NDC"}],"standard_charges":[{"gross_charge":10.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [27490]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-3582-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2552]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-7123-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-106-11","type":"NDC"}],"standard_charges":[{"gross_charge":41.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM IV SYRINGE 15 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [508158]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-637-52","type":"NDC"}],"standard_charges":[{"gross_charge":24.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-807-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-782-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-064-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-064-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION [191429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-103-10","type":"NDC"}],"standard_charges":[{"gross_charge":1444.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROCORTISONE 1 % LOTION [3728]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6373633942","type":"NDC"}],"standard_charges":[{"gross_charge":19.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 10 MG TABLET [3772]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-483-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (OCTAGAM) 5%-MALT-IGA OVER 50 MCG/ML IV SOLN [175925]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68982-840-03","type":"NDC"}],"standard_charges":[{"gross_charge":1057.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FUROSEMIDE 40 MG TABLET [3295]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-117-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-6300-5","type":"NDC"}],"standard_charges":[{"gross_charge":78.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0065-0648-35","type":"NDC"}],"standard_charges":[{"gross_charge":647.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0268-15","type":"NDC"}],"standard_charges":[{"gross_charge":110.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4276-16","type":"NDC"}],"standard_charges":[{"gross_charge":4.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11076]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7075-26","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9558-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0033-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-2020-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-900-99","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OFLOXACIN 0.3 % EYE DROPS [19746]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-713-10","type":"NDC"}],"standard_charges":[{"gross_charge":46.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"4116705840","type":"NDC"}],"standard_charges":[{"gross_charge":5.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42571-162-42","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-013-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57237-316-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-661-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-649-94","type":"NDC"}],"standard_charges":[{"gross_charge":246.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 25 MG TABLET [3700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-327-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66220-207-30","type":"NDC"}],"standard_charges":[{"gross_charge":2087.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70860-100-41","type":"NDC"}],"standard_charges":[{"gross_charge":8.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-5010-1","type":"NDC"}],"standard_charges":[{"gross_charge":74.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [6654]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3727-63","type":"NDC"}],"standard_charges":[{"gross_charge":121.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [127673]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121072208","type":"NDC"}],"standard_charges":[{"gross_charge":40.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0553-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET [14087]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0484-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1159-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BROMOCRIPTINE 2.5 MG TABLET [9297]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0574-0106-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0493-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG CAPSULE [98]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1987-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZITHROMYCIN 250 MG TABLET [20943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7350-06","type":"NDC"}],"standard_charges":[{"gross_charge":3.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 200 MG TABLET [3841]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7914-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-580-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE 4 MG TABLETS IN A DOSE PACK [4991]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59746-001-03","type":"NDC"}],"standard_charges":[{"gross_charge":18.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-016-01","type":"NDC"}],"standard_charges":[{"gross_charge":80.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62332-751-50","type":"NDC"}],"standard_charges":[{"gross_charge":71.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62332-779-31","type":"NDC"}],"standard_charges":[{"gross_charge":164.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-488-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION [169778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64764-300-20","type":"NDC"}],"standard_charges":[{"gross_charge":25999.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFPODOXIME 200 MG TABLET [9469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-096-20","type":"NDC"}],"standard_charges":[{"gross_charge":7.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/10ML INJECTION SYRINGE [2848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3316-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0552-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-3243-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE IVPB 5 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7811-24","type":"NDC"}],"standard_charges":[{"gross_charge":2758.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0740-20","type":"NDC"}],"standard_charges":[{"gross_charge":61.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-345-32","type":"NDC"}],"standard_charges":[{"gross_charge":11.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-319-25","type":"NDC"}],"standard_charges":[{"gross_charge":15.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 20 MG IV SOLUTION [130905]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45567-0040-2","type":"NDC"}],"standard_charges":[{"gross_charge":2270.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-730-30","type":"NDC"}],"standard_charges":[{"gross_charge":7.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-491-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-169-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57894-160-01","type":"NDC"}],"standard_charges":[{"gross_charge":1316.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"},{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-721-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-064-01","type":"NDC"}],"standard_charges":[{"gross_charge":14.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.4 MG/10 ML (40 MCG/ML) IN 0.9 %SOD.CHLORIDE IV SYRINGE [131065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9031-1","type":"NDC"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0795-15","type":"NDC"}],"standard_charges":[{"gross_charge":10.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"POTASSIUM CITRATE-CITRIC ACID 1,100 MG-334 MG/5 ML ORAL SOLUTION [22646]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121067616","type":"NDC"}],"standard_charges":[{"gross_charge":61.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9398-01","type":"NDC"}],"standard_charges":[{"gross_charge":67.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-25","type":"NDC"}],"standard_charges":[{"gross_charge":22.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4002-25","type":"NDC"}],"standard_charges":[{"gross_charge":55.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-0063-01","type":"NDC"}],"standard_charges":[{"gross_charge":143.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-439-93","type":"NDC"}],"standard_charges":[{"gross_charge":8365.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-198-30","type":"NDC"}],"standard_charges":[{"gross_charge":28.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"60687-662-91","type":"NDC"}],"standard_charges":[{"gross_charge":35.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-756-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [9774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-817-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-57","type":"NDC"}],"standard_charges":[{"gross_charge":36.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-97","type":"NDC"}],"standard_charges":[{"gross_charge":16.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-BOTOX 100 UNITS (20 UNITS/ML) IN 0.9% SODIUM CHLORIDE SYRINGE [508123]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [181531]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-0809-01","type":"NDC"}],"standard_charges":[{"gross_charge":1375.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION WRAPPER [421069]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0088-2220-33","type":"NDC"}],"standard_charges":[{"gross_charge":170.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1781-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [25246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9887-50","type":"NDC"}],"standard_charges":[{"gross_charge":7.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ISOSORBIDE MONONITRATE 20 MG TABLET [10357]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2620-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-9119-16","type":"NDC"}],"standard_charges":[{"gross_charge":32.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"CHLORPROMAZINE 25 MG TABLET [1656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7130-06","type":"NDC"}],"standard_charges":[{"gross_charge":4.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 2,000 UNIT/ML INJECTION SOLUTION [9939]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-126-01","type":"NDC"}],"standard_charges":[{"gross_charge":95.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIOGLITAZONE 15 MG TABLET [25528]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-391-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-494-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-05","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [30807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-5050-1","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 2 MG/ML INJECTION SYRINGE [5170]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-004-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.1 % EYE DROPS [70262]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"82182-321-05","type":"NDC"}],"standard_charges":[{"gross_charge":321.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-778-41","type":"NDC"}],"standard_charges":[{"gross_charge":6.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8215-17","type":"NDC"}],"standard_charges":[{"gross_charge":8.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3425-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1781-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9552-01","type":"NDC"}],"standard_charges":[{"gross_charge":40.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIAZEPAM 5 MG TABLET [2405]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0172-3926-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION (PEDS) [978729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUMATRIPTAN 50 MG TABLET [15328]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-532-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT [8118]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"21922-063-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS [31025]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-884-31","type":"NDC"}],"standard_charges":[{"gross_charge":110.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"4203710478","type":"NDC"}],"standard_charges":[{"gross_charge":14.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOLIC ACID 400 MCG TABLET [3234]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026834611","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55566-2200-0","type":"NDC"}],"standard_charges":[{"gross_charge":139.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"TAMSULOSIN 0.4 MG CAPSULE [103890]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-598-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-675-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM IODIDE-123 CAPSULE (MICROCURIE) [464103]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69945-602-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-436-88","type":"NDC"}],"standard_charges":[{"gross_charge":15.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3505-47","type":"NDC"}],"standard_charges":[{"gross_charge":103.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETRACAINE HCL (PF) 0.5 % EYE DROPS [131372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0741-14","type":"NDC"}],"standard_charges":[{"gross_charge":35.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LACTATED RINGERS IV BOLUS [400296]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0597-0355-56","type":"NDC"}],"standard_charges":[{"gross_charge":8.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3110-90","type":"NDC"}],"standard_charges":[{"gross_charge":9.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 25 MG TABLET [15748]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7308-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-591-80","type":"NDC"}],"standard_charges":[{"gross_charge":179.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-306-60","type":"NDC"}],"standard_charges":[{"gross_charge":11.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-116-02","type":"NDC"}],"standard_charges":[{"gross_charge":160.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-478-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-210-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET [2008]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026885211","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51672-1260-3","type":"NDC"}],"standard_charges":[{"gross_charge":50.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-797-42","type":"NDC"}],"standard_charges":[{"gross_charge":7.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-464-31","type":"NDC"}],"standard_charges":[{"gross_charge":14.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORTRIPTYLINE 10 MG CAPSULE [5674]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75907-069-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MOMETASONE-FORMOTEROL HFA 100 MCG-5 MCG/ACTUATION AEROSOL INHALER [105698]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"78206-127-01","type":"NDC"}],"standard_charges":[{"gross_charge":276.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [173958]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0006-3026-04","type":"NDC"}],"standard_charges":[{"gross_charge":16672.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9606-01","type":"NDC"}],"standard_charges":[{"gross_charge":69.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION [9791]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0683-04","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1273-32","type":"NDC"}],"standard_charges":[{"gross_charge":87.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-33","type":"NDC"}],"standard_charges":[{"gross_charge":12.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9558-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACCHAROMYCES BOULARDII 250 MG CAPSULE [37343]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0414200007","type":"NDC"}],"standard_charges":[{"gross_charge":1.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0101-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17478-404-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27241-098-09","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-009-24","type":"NDC"}],"standard_charges":[{"gross_charge":9.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [108096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-262-02","type":"NDC"}],"standard_charges":[{"gross_charge":146.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-211-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FLUPHENAZINE 5 MG TABLET [3221]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-487-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6148-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 40 MG TABLET [11112]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-908-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1049-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [169676]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-7678-01","type":"NDC"}],"standard_charges":[{"gross_charge":21423.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9660-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-03","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9159-30","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0464-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-0201-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [127344]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0121-04","type":"NDC"}],"standard_charges":[{"gross_charge":35.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6027-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-301-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TDAP VACCINE (BOOSTRIX/ADACEL) ADOLESCENT/ADULT WRAPPER [505075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-400-58","type":"NDC"}],"standard_charges":[{"gross_charge":85.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 100 MG TABLET [310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-677-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MECLIZINE 12.5 MG TABLET [12024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-775-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-229-94","type":"NDC"}],"standard_charges":[{"gross_charge":23.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-614-16","type":"NDC"}],"standard_charges":[{"gross_charge":9.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [198416]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72485-201-01","type":"NDC"}],"standard_charges":[{"gross_charge":87.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MORPHINE 2 MG/ML INJECTION WRAPPER [339565]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-004-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0209-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-2026-23","type":"NDC"}],"standard_charges":[{"gross_charge":29.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SYRINGE [123669]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1312-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2340-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML ORAL SUSPENSION [81428]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0520-76","type":"NDC"}],"standard_charges":[{"gross_charge":46.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"12870-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":2.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-05","type":"NDC"}],"standard_charges":[{"gross_charge":6847.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-486-10","type":"NDC"}],"standard_charges":[{"gross_charge":34.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-468-10","type":"NDC"}],"standard_charges":[{"gross_charge":157.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-1000-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-008-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43825-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ATENOLOL 25 MG TABLET [717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-605-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-26","type":"NDC"}],"standard_charges":[{"gross_charge":11.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-489-27","type":"NDC"}],"standard_charges":[{"gross_charge":57.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-27","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-27","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [169631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-572-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION [9501]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-4175-73","type":"NDC"}],"standard_charges":[{"gross_charge":19.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION [1299]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-4766-05","type":"NDC"}],"standard_charges":[{"gross_charge":5.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0281-0326-08","type":"NDC"}],"standard_charges":[{"gross_charge":6.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0123-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1215-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE [165310]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-04","type":"NDC"}],"standard_charges":[{"gross_charge":7.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4713-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [106364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9045-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [129971]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-673-77","type":"NDC"}],"standard_charges":[{"gross_charge":15.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-1100-1","type":"NDC"}],"standard_charges":[{"gross_charge":97.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-252-51","type":"NDC"}],"standard_charges":[{"gross_charge":970.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"HYDRALAZINE 10 MG TABLET [3698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50111-398-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-252-20","type":"NDC"}],"standard_charges":[{"gross_charge":7.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-885-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.15 % EYE DROPS [31158]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-144-05","type":"NDC"}],"standard_charges":[{"gross_charge":362.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION [9501]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67877-544-88","type":"NDC"}],"standard_charges":[{"gross_charge":24.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69097-168-48","type":"NDC"}],"standard_charges":[{"gross_charge":4.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE 5 MG/ML IV SYRINGE WRAPPER [339196]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0270-0556-15","type":"NDC"}],"standard_charges":[{"gross_charge":369.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9662-35","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0123-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SOLUTION [181528]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2552-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION [127257]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0487-9901-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUCONAZOLE 100 MG TABLET [10044]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-691-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE [119007]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-802-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLOPATADINE 0.6 % NASAL SPRAY [91483]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-104-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 4 MG GUM [10718]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-651-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-459-01","type":"NDC"}],"standard_charges":[{"gross_charge":58.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-304-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-401-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-616-10","type":"NDC"}],"standard_charges":[{"gross_charge":15.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PACLITAXEL PROTEIN-BOUND 100 MG INTRAVENOUS SUSPENSION [40475]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68817-134-50","type":"NDC"}],"standard_charges":[{"gross_charge":4574.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-410-80","type":"NDC"}],"standard_charges":[{"gross_charge":5.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"},{"gross_charge":2.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AA 2.75% NO.2-DEXTROSE 5 %-ELECTROLYTES NO.29 (CLINIMIX E 2.75/5) IV SOLN [27946]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-7020-01","type":"NDC"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-6470-16","type":"NDC"}],"standard_charges":[{"gross_charge":44.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [7309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6637-34","type":"NDC"}],"standard_charges":[{"gross_charge":25.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9904-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [19596]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0998-0615-05","type":"NDC"}],"standard_charges":[{"gross_charge":193.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL JELLY [4448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-711-30","type":"NDC"}],"standard_charges":[{"gross_charge":15.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOMIPRAMINE 25 MG CAPSULE [9635]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-4011-6","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZELASTINE 137 MCG (0.1 %) NASAL SPRAY [19179]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59651-214-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR [32631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-1316-3","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6169-0","type":"NDC"}],"standard_charges":[{"gross_charge":58.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP [131272]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-576-40","type":"NDC"}],"standard_charges":[{"gross_charge":12.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 1 % EYE DROPS [6279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-203-15","type":"NDC"}],"standard_charges":[{"gross_charge":181.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-652-10","type":"NDC"}],"standard_charges":[{"gross_charge":49.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-PHENYLEPHRINE INFUSION 10 MG/250 ML (40 MCG/ML) IN NS [440061]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-751-00","type":"NDC"}],"standard_charges":[{"gross_charge":862.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROXYZINE HCL 25 MG TABLET [3774]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-486-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [24559]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6809411459","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [198416]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER [105699]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"78206-126-59","type":"NDC"}],"standard_charges":[{"gross_charge":166.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"GENTAMICIN 100 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10112]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0511-41","type":"NDC"}],"standard_charges":[{"gross_charge":6.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEVETIRACETAM 500 MG TABLET [26817]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7124-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL [197250]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"1031028313","type":"NDC"}],"standard_charges":[{"gross_charge":19.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-424-06","type":"NDC"}],"standard_charges":[{"gross_charge":193.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42192-339-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54288-167-01","type":"NDC"}],"standard_charges":[{"gross_charge":249.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MVI, ADULT WITH VIT K 3300 UNIT-150 MCG WRAPPER [339599]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54643-5649-1","type":"NDC"}],"standard_charges":[{"gross_charge":27.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 25 MG TABLET [3700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-733-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"TIMOLOL MALEATE 0.25 % EYE DROPS [11561]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64980-513-05","type":"NDC"}],"standard_charges":[{"gross_charge":35.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-681-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-368-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-001-59","type":"NDC"}],"standard_charges":[{"gross_charge":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-411-82","type":"NDC"}],"standard_charges":[{"gross_charge":23.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE [14626]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75834-158-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0081-30","type":"NDC"}],"standard_charges":[{"gross_charge":257.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SEMAGLUTIDE 2 MG/DOSE (8 MG/3 ML) SUBCUTANEOUS PEN INJECTOR [198901]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0169-4772-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7610-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-4114-50","type":"NDC"}],"standard_charges":[{"gross_charge":15.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3365-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14789-128-07","type":"NDC"}],"standard_charges":[{"gross_charge":80.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC99 SULFUR COLLOID - FILTERED [485601]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45567-0030-1","type":"NDC"}],"standard_charges":[{"gross_charge":230460.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-168-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-345-01","type":"NDC"}],"standard_charges":[{"gross_charge":87.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 10 MG TABLET [3733]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-414-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-016-01","type":"NDC"}],"standard_charges":[{"gross_charge":82.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TIMOLOL MALEATE 0.5 % EYE DROPS [11562]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-227-05","type":"NDC"}],"standard_charges":[{"gross_charge":14.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"66993-019-68","type":"NDC"}],"standard_charges":[{"gross_charge":88.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-403-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0795-15","type":"NDC"}],"standard_charges":[{"gross_charge":10.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS [400297]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0125-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7101-67","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-25","type":"NDC"}],"standard_charges":[{"gross_charge":26.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MULTIVITAMIN TABLET WRAPPER [339456]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904053061","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 25 MCG TABLET [4420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6949-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7193-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7252-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-801-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-2062-0","type":"NDC"}],"standard_charges":[{"gross_charge":14.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREGABALIN 50 MG CAPSULE [42163]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-484-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 125 MG CAPSULE [11628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62559-390-50","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-286-31","type":"NDC"}],"standard_charges":[{"gross_charge":22.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-423-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68180-963-01","type":"NDC"}],"standard_charges":[{"gross_charge":45.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70720-951-30","type":"NDC"}],"standard_charges":[{"gross_charge":7960.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8068102500","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-3890-1","type":"NDC"}],"standard_charges":[{"gross_charge":2587.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [178147]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0006-5423-02","type":"NDC"}],"standard_charges":[{"gross_charge":369.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREGABALIN 50 MG CAPSULE [42163]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-1013-68","type":"NDC"}],"standard_charges":[{"gross_charge":28.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9510-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-48","type":"NDC"}],"standard_charges":[{"gross_charge":4.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION [11403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0048-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-3390-04","type":"NDC"}],"standard_charges":[{"gross_charge":10.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE [38224]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-4116-37","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14789-134-07","type":"NDC"}],"standard_charges":[{"gross_charge":26.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-243-31","type":"NDC"}],"standard_charges":[{"gross_charge":69.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-216-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP [207999]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5093009802","type":"NDC"}],"standard_charges":[{"gross_charge":17.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARTIFICIAL TEAR BOTTLE WRAPPER [632222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"58790-001-15","type":"NDC"}],"standard_charges":[{"gross_charge":26.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-626-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 100 MCG TABLET [10628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-735-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WARFARIN 5 MG TABLET [8751]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-994-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL IV INJECTION [410075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-00","type":"NDC"}],"standard_charges":[{"gross_charge":94.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-619-10","type":"NDC"}],"standard_charges":[{"gross_charge":180.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MINOXIDIL 2.5 MG TABLET [5115]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-204-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLCELLULOSE (WITH SUGAR) ORAL POWDER [19739]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0068041830","type":"NDC"}],"standard_charges":[{"gross_charge":148.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [174833]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0078-0825-81","type":"NDC"}],"standard_charges":[{"gross_charge":18638.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9638-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2720-31","type":"NDC"}],"standard_charges":[{"gross_charge":9.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0591-2070-26","type":"NDC"}],"standard_charges":[{"gross_charge":19.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14789-134-07","type":"NDC"}],"standard_charges":[{"gross_charge":55.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROPINIROLE 0.25 MG TABLET [21688]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-268-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-437-91","type":"NDC"}],"standard_charges":[{"gross_charge":2091.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49348-740-27","type":"NDC"}],"standard_charges":[{"gross_charge":9.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2114-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-345-01","type":"NDC"}],"standard_charges":[{"gross_charge":87.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [190450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-206-01","type":"NDC"}],"standard_charges":[{"gross_charge":1292.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-752-33","type":"NDC"}],"standard_charges":[{"gross_charge":12.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-285-28","type":"NDC"}],"standard_charges":[{"gross_charge":27.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-527-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-528-10","type":"NDC"}],"standard_charges":[{"gross_charge":55.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IVIG (OCTAGAM) 5%-MALT-IGA OVER 50 MCG/ML IV SOLN [175925]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68982-840-04","type":"NDC"}],"standard_charges":[{"gross_charge":2127.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-500-41","type":"NDC"}],"standard_charges":[{"gross_charge":7.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3183-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [11081]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7115-09","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [127343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0121-08","type":"NDC"}],"standard_charges":[{"gross_charge":52.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WARFARIN 5 MG TABLET [8751]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-1216-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-438-20","type":"NDC"}],"standard_charges":[{"gross_charge":4182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"58980-410-12","type":"NDC"}],"standard_charges":[{"gross_charge":4.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-431-99","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-616-44","type":"NDC"}],"standard_charges":[{"gross_charge":2.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARIPRAZINE 1.5 MG CAPSULE [178797]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61874-115-11","type":"NDC"}],"standard_charges":[{"gross_charge":137.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE [128173]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6425333335","type":"NDC"}],"standard_charges":[{"gross_charge":1.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUMATRIPTAN 25 MG TABLET [15327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-146-36","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-657-25","type":"NDC"}],"standard_charges":[{"gross_charge":245.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-567-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-282-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IMIPRAMINE 10 MG TABLET [3860]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69584-425-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-016-15","type":"NDC"}],"standard_charges":[{"gross_charge":44.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":0.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [196862]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0005-2000-01","type":"NDC"}],"standard_charges":[{"gross_charge":658.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3073-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"POVIDONE-IODINE 5 % EYE SOLUTION [19791]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0411-30","type":"NDC"}],"standard_charges":[{"gross_charge":34.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9785-01","type":"NDC"}],"standard_charges":[{"gross_charge":45.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1708-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1183-65","type":"NDC"}],"standard_charges":[{"gross_charge":43.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1202-15","type":"NDC"}],"standard_charges":[{"gross_charge":3.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLN (BELRAPZO) [606226]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42367-521-25","type":"NDC"}],"standard_charges":[{"gross_charge":7198.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUCRALFATE 1 GRAM TABLET [11442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-753-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [192838]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55135-132-01","type":"NDC"}],"standard_charges":[{"gross_charge":7252.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPROPION HCL 75 MG TABLET [9322]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-340-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG TABLET [4423]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-497-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-03","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOCARBAMOL 500 MG TABLET [4971]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-166-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-433-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70756-404-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70756-612-12","type":"NDC"}],"standard_charges":[{"gross_charge":6.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72888-125-26","type":"NDC"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE 5 % TOPICAL OINTMENT [41831]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0204-37","type":"NDC"}],"standard_charges":[{"gross_charge":68.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE IVPB 5 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-5535-32","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0085-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION (PEDS) [978730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM ER 120 MG CAPSULE,EXTENDED RELEASE 12 HR [11892]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-6120-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 4 MG GUM [10718]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1372-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"1000670028","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-501-64","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-033-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-387-11","type":"NDC"}],"standard_charges":[{"gross_charge":207.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-211-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [174248]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50090-1723-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE [189787]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-998-02","type":"NDC"}],"standard_charges":[{"gross_charge":3755.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-PHENYLEPHRINE INFUSION 10 MG/250 ML (40 MCG/ML) IN NS [440061]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-751-00","type":"NDC"}],"standard_charges":[{"gross_charge":862.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-002-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHADONE 5 MG/5 ML ORAL SOLUTION [4952]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-031-59","type":"NDC"}],"standard_charges":[{"gross_charge":4.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1643-1","type":"NDC"}],"standard_charges":[{"gross_charge":8.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN IN LACTATED RINGERS 30 UNIT/500 ML INTRAVENOUS SOLUTION [128127]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71285-6039-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-0293-05","type":"NDC"}],"standard_charges":[{"gross_charge":25.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0904-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1870-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0512-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-1391-21","type":"NDC"}],"standard_charges":[{"gross_charge":11.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-25","type":"NDC"}],"standard_charges":[{"gross_charge":17.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 10 MG CAPSULE [10069]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7345-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-01","type":"NDC"}],"standard_charges":[{"gross_charge":30.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MELATONIN 3 MG TABLET [16830]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026852411","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 112 MCG TABLET [10404]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-508-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-877-45","type":"NDC"}],"standard_charges":[{"gross_charge":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-483-20","type":"NDC"}],"standard_charges":[{"gross_charge":4.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"COCAINE 4 % NASAL SOLUTION [186001]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64950-362-04","type":"NDC"}],"standard_charges":[{"gross_charge":426.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RISPERIDONE 1 MG TABLET [18313]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-272-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-494-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"EPHEDRINE 5 MG/ML IV SYRINGE WRAPPER [339196]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TECHNETIUM TC99M MEDRONATE PSD UT 30 MCI [450038]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9002-11","type":"NDC"}],"standard_charges":[{"gross_charge":367.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [183720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9545-50","type":"NDC"}],"standard_charges":[{"gross_charge":10.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1886-22","type":"NDC"}],"standard_charges":[{"gross_charge":5.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LENALIDOMIDE 15 MG CAPSULE [76783]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0480-1244-21","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-2555-41","type":"NDC"}],"standard_charges":[{"gross_charge":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6008-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6147-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7983-61","type":"NDC"}],"standard_charges":[{"gross_charge":9.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"GENTAMICIN 0.3 % EYE DROPS [3428]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-283-10","type":"NDC"}],"standard_charges":[{"gross_charge":9.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-319-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 40 MG TABLET [11112]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-667-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-221-01","type":"NDC"}],"standard_charges":[{"gross_charge":8118.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-TRANEXEMIC ACID INFUSION 3,000 MG/250 ML IN NS [975035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61990-0611-2","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ARIPIPRAZOLE 2 MG TABLET [70306]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-097-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FINASTERIDE 5 MG TABLET [10037]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-149-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE(PF) 0.2 %-0.9 % SODCHL 545 ML INFIL,HI VAR RATE ELAST PUMP [188549]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70360-079-51","type":"NDC"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE [182441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-009-96","type":"NDC"}],"standard_charges":[{"gross_charge":7.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0544-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"MIDODRINE 2.5 MG TABLET [10609]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1901-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 10 MG TABLET [9506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-3637-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ INGREDIENT ORDERABLE [425004]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-54","type":"NDC"}],"standard_charges":[{"gross_charge":24.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6022-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11074]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7074-26","type":"NDC"}],"standard_charges":[{"gross_charge":7.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-542-02","type":"NDC"}],"standard_charges":[{"gross_charge":17.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-608-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-249-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOCARBAMOL 500 MG TABLET [4971]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-559-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62332-811-02","type":"NDC"}],"standard_charges":[{"gross_charge":68.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDAPAMIDE 2.5 MG TABLET [3879]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62559-511-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-65","type":"NDC"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION [8444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-295-66","type":"NDC"}],"standard_charges":[{"gross_charge":67.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER [40697]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"66993-078-96","type":"NDC"}],"standard_charges":[{"gross_charge":328.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESCITALOPRAM 10 MG TABLET [33512]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-617-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-778-41","type":"NDC"}],"standard_charges":[{"gross_charge":6.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHADONE 10 MG TABLET [4953]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0710-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121059530","type":"NDC"}],"standard_charges":[{"gross_charge":3.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IRON SUCROSE IV PUSH WRAPPER (WIN) [339404]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2340-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROSUVASTATIN 5 MG TABLET [36612]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-179-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39786]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-115-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42211-102-43","type":"NDC"}],"standard_charges":[{"gross_charge":475.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 0.5 % EYE DROPS [19733]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42571-137-25","type":"NDC"}],"standard_charges":[{"gross_charge":17.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [125727]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-060-70","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE MALEATE 10 MG TABLET [6582]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-685-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 100 MG TABLET [310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-205-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-2075-1","type":"NDC"}],"standard_charges":[{"gross_charge":10.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-252-20","type":"NDC"}],"standard_charges":[{"gross_charge":5.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ANASTROZOLE 1 MG TABLET [16205]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-112-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORTRIPTYLINE 25 MG CAPSULE [5675]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-293-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-447-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"633232-367-41","type":"NDC"}],"standard_charges":[{"gross_charge":307.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 VIAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-285-28","type":"NDC"}],"standard_charges":[{"gross_charge":27.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66758-190-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MORPHINE 5 MG/ML INJECTION SYRINGE [124938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-006-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9320-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4276-16","type":"NDC"}],"standard_charges":[{"gross_charge":4.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-6510-01","type":"NDC"}],"standard_charges":[{"gross_charge":594.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9094-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0376-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"WARFARIN 1 MG TABLET [11664]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-1211-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-01","type":"NDC"}],"standard_charges":[{"gross_charge":1380.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAMIPEXOLE 0.125 MG TABLET [21287]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-091-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-500-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 250 MG/50 ML IN D5W INFUSION (PREMIX) [979042]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-500-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-253-10","type":"NDC"}],"standard_charges":[{"gross_charge":138.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 25 MCG TABLET [4420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-453-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 2.5 MG TABLET [13089]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-656-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-485-27","type":"NDC"}],"standard_charges":[{"gross_charge":5.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RISPERIDONE 0.25 MG TABLET [25519]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-270-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 200 MG TABLET [9066]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-371-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71399-1017-3","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":1039.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-0237-49","type":"NDC"}],"standard_charges":[{"gross_charge":54.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [121432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1160-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIBUCAINE 1 % TOPICAL OINTMENT [2412]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1211-95","type":"NDC"}],"standard_charges":[{"gross_charge":9.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6175-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CALCIUM 250 MG (AS CARBONATE)-VITAMIN D3 3.125 MCG (125 UNIT) TABLET [128032]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"3786482699","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-502-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-130-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-299-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MELOXICAM 7.5 MG TABLET [20566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-525-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 30 MG TABLET [2475]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-745-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-226-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-093-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMLODIPINE 2.5 MG TABLET [9070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-197-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE [13184]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-292-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68682-994-98","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN IN LACTATED RINGERS 30 UNIT/500 ML INTRAVENOUS SOLUTION [128127]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71285-6039-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-719-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/10ML INJECTION SYRINGE [2848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3318-1","type":"NDC"}],"standard_charges":[{"gross_charge":28.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETRACAINE HCL (PF) 0.5 % EYE DROPS [131372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0741-14","type":"NDC"}],"standard_charges":[{"gross_charge":36.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0581-04","type":"NDC"}],"standard_charges":[{"gross_charge":653.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10 % IV BOLUS [400302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AA 5% NO.6-DEXTROSE 15%-LYTES NO.23 (CLINIMIX E 5/15) IV SOLN [27963]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1123-04","type":"NDC"}],"standard_charges":[{"gross_charge":216.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-FENTANYL-0.9% SODIUM CHLORIDE IV [440067]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9093-45","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 0.2 MG/ML INJECTION SYRINGE [193269]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6259-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MONTELUKAST 10 MG TABLET [22509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-726-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-235-25","type":"NDC"}],"standard_charges":[{"gross_charge":12.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN 50 MG CHEWABLE TABLET [11018]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-156-95","type":"NDC"}],"standard_charges":[{"gross_charge":2.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-492-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-278-10","type":"NDC"}],"standard_charges":[{"gross_charge":147.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-182-00","type":"NDC"}],"standard_charges":[{"gross_charge":17.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"TRIHEXYPHENIDYL 2 MG TABLET [8166]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69452-241-20","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-410-82","type":"NDC"}],"standard_charges":[{"gross_charge":6.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-401-41","type":"NDC"}],"standard_charges":[{"gross_charge":14.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MORPHINE INFUSION 1 MG/ML (WIN) [632108]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4006-20","type":"NDC"}],"standard_charges":[{"gross_charge":28.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM IODIDE I-131 CAP PER MCI - THERAPEUTIC [450057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9002-23","type":"NDC"}],"standard_charges":[{"gross_charge":29.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION (DRY VIAL) [978603]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9162-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER [339457]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9380-01","type":"NDC"}],"standard_charges":[{"gross_charge":32.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-65","type":"NDC"}],"standard_charges":[{"gross_charge":0.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0007-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6007-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-0493-01","type":"NDC"}],"standard_charges":[{"gross_charge":95.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7109-09","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-50","type":"NDC"}],"standard_charges":[{"gross_charge":7103.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"3932810710","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION [180147]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-917-01","type":"NDC"}],"standard_charges":[{"gross_charge":32140.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-141-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 250 MG TABLET,DELAYED RELEASE [121686]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"52536-180-03","type":"NDC"}],"standard_charges":[{"gross_charge":11.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54838-501-15","type":"NDC"}],"standard_charges":[{"gross_charge":81.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-145-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-489-02","type":"NDC"}],"standard_charges":[{"gross_charge":50.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-930-08","type":"NDC"}],"standard_charges":[{"gross_charge":4.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68180-295-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.5 MG/5 ML (100 MCG/ML)IN 0.9 % SOD.CHLORIDE IV SYRINGE [130890]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-17","type":"NDC"}],"standard_charges":[{"gross_charge":30.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0152-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CALAMINE 8 %-ZINC OXIDE 8 % LOTION [28055]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-2533-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6320-78","type":"NDC"}],"standard_charges":[{"gross_charge":2.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 100 MG TABLET [310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7041-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-283-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-301-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ANASTROZOLE 1 MG TABLET [16205]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-075-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 50 MG TABLET [3701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-076-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-3275-3","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 0.5 MG TABLET [9637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-861-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION [7028]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-259-30","type":"NDC"}],"standard_charges":[{"gross_charge":7.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-286-31","type":"NDC"}],"standard_charges":[{"gross_charge":22.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-485-27","type":"NDC"}],"standard_charges":[{"gross_charge":9.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65862-534-50","type":"NDC"}],"standard_charges":[{"gross_charge":10.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-196-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-136-02","type":"NDC"}],"standard_charges":[{"gross_charge":61.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-2223-19","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1159-19","type":"NDC"}],"standard_charges":[{"gross_charge":5.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION WRAPPER [421038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINACLOTIDE 145 MCG CAPSULE [117352]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0456-1201-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE 200 MG IRON/10 ML IV PUSH (WIN) [975062]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2310-01","type":"NDC"}],"standard_charges":[{"gross_charge":190.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [124737]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3433-46","type":"NDC"}],"standard_charges":[{"gross_charge":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-2725-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IBUPROFEN 200 MG TABLET [3841]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7914-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43825-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":99.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"URSODIOL 20MG/ML ORAL LIQUID (SUGAR FREE) [975052]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-796-11","type":"NDC"}],"standard_charges":[{"gross_charge":15.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 1 MG TABLET [9310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-384-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-756-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FLUVOXAMINE 50 MG TABLET [10085]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62559-159-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALACYCLOVIR 500 MG TABLET [13133]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63304-904-90","type":"NDC"}],"standard_charges":[{"gross_charge":2.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-472-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 10 MG TABLET [10449]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-334-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 1 MG/ML PCA (WIN) [632107]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-45","type":"NDC"}],"standard_charges":[{"gross_charge":28.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE [30961]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0088-13","type":"NDC"}],"standard_charges":[{"gross_charge":1.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0248-01","type":"NDC"}],"standard_charges":[{"gross_charge":29.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FOLIC ACID 1 MG TABLET [3233]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"11534-165-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CROMOLYN 5.2 MG/SPRAY (4 %) NASAL SPRAY [24325]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"1483201103","type":"NDC"}],"standard_charges":[{"gross_charge":8.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-705-87","type":"NDC"}],"standard_charges":[{"gross_charge":24.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51754-5001-1","type":"NDC"}],"standard_charges":[{"gross_charge":15.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-400-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 5 MG TABLET [10209]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-844-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION [32855]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-326-18","type":"NDC"}],"standard_charges":[{"gross_charge":102.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-616-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-681-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":1039.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0018-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY [16071]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-0046-41","type":"NDC"}],"standard_charges":[{"gross_charge":50.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV [18315]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1075-02","type":"NDC"}],"standard_charges":[{"gross_charge":32.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [7309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6637-24","type":"NDC"}],"standard_charges":[{"gross_charge":40.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-7604-25","type":"NDC"}],"standard_charges":[{"gross_charge":27.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [24844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1161-34","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [11634]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0703-2914-03","type":"NDC"}],"standard_charges":[{"gross_charge":17.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-6200-1","type":"NDC"}],"standard_charges":[{"gross_charge":44.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLOBAZAM 10 MG TABLET [112703]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-423-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-130-17","type":"NDC"}],"standard_charges":[{"gross_charge":51.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-35","type":"NDC"}],"standard_charges":[{"gross_charge":27.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-614-00","type":"NDC"}],"standard_charges":[{"gross_charge":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION [91651]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65649-551-02","type":"NDC"}],"standard_charges":[{"gross_charge":455.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-595-08","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-152-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CARFILZOMIB 60 MG INTRAVENOUS SOLUTION [117047]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"76075-101-01","type":"NDC"}],"standard_charges":[{"gross_charge":9823.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREDNISONE 5 MG TABLET [6497]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8724-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [122026]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0431-30","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1778-15","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2050-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904-5354-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-06","type":"NDC"}],"standard_charges":[{"gross_charge":5482.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-146-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-880-14","type":"NDC"}],"standard_charges":[{"gross_charge":11.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.1 % EYE DROPS [70262]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-0577-3","type":"NDC"}],"standard_charges":[{"gross_charge":1381.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6159-0","type":"NDC"}],"standard_charges":[{"gross_charge":8.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-145-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64253-900-30","type":"NDC"}],"standard_charges":[{"gross_charge":22.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-310-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MONTELUKAST 10 MG TABLET [22509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-875-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-167-50","type":"NDC"}],"standard_charges":[{"gross_charge":415.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72485-409-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132-0201-40","type":"NDC"}],"standard_charges":[{"gross_charge":3.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"FLUTICASONE FUR. 100 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER [185062]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0887-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.000831,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK [128040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0551-11","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1007-02","type":"NDC"}],"standard_charges":[{"gross_charge":28.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 500 MG/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [11632]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3551-48","type":"NDC"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 5 MG/ML INTRANASAL SOLUTION [632149]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2308-22","type":"NDC"}],"standard_charges":[{"gross_charge":2.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LATANOPROST 0.005 % EYE DROPS [18621]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-463-25","type":"NDC"}],"standard_charges":[{"gross_charge":49.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-101-67","type":"NDC"}],"standard_charges":[{"gross_charge":2.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [11634]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-235-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAZOSIN 2 MG CAPSULE [6469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-272-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG CAPSULE [9499]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-152-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"ARIPIPRAZOLE 10 MG TABLET [34369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-099-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-423-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN HCL 150 MG CAPSULE [1740]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-243-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FLUOROURACIL IV INJECTION [410075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70700-188-22","type":"NDC"}],"standard_charges":[{"gross_charge":82.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75907-023-11","type":"NDC"}],"standard_charges":[{"gross_charge":18.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0914-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 200 MG TABLET [9066]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-0147-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AA 5% NO.6-DEXTROSE 15%-LYTES NO.23 (CLINIMIX E 5/15) IV SOLN [27963]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1147-03","type":"NDC"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9159-30","type":"NDC"}],"standard_charges":[{"gross_charge":10.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 10 MG TABLET [6494]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6923-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-132-82","type":"NDC"}],"standard_charges":[{"gross_charge":13.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-420-24","type":"NDC"}],"standard_charges":[{"gross_charge":18.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"46122-789-29","type":"NDC"}],"standard_charges":[{"gross_charge":9.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TAMSULOSIN 0.4 MG CAPSULE [103890]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-740-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-128-24","type":"NDC"}],"standard_charges":[{"gross_charge":16.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-225-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61958-0701-1","type":"NDC"}],"standard_charges":[{"gross_charge":177.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-681-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-368-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-442-20","type":"NDC"}],"standard_charges":[{"gross_charge":32.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-477-47","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID [130903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6961800815","type":"NDC"}],"standard_charges":[{"gross_charge":2.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-725-01","type":"NDC"}],"standard_charges":[{"gross_charge":792.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESVENLAFAXINE SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [91074]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0008-1222-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 20 MG TABLET [3294]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-8297-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION [11403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0047-47","type":"NDC"}],"standard_charges":[{"gross_charge":30.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1.5 GRAM/300 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [206396]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0124-04","type":"NDC"}],"standard_charges":[{"gross_charge":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6729-11","type":"NDC"}],"standard_charges":[{"gross_charge":10.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATORVASTATIN 10 MG TABLET [19176]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6290-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-591-81","type":"NDC"}],"standard_charges":[{"gross_charge":216.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION [189592]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-918-01","type":"NDC"}],"standard_charges":[{"gross_charge":22272.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETIC ACID (BULK) 5 % LIQUID [14702]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5155200556","type":"NDC"}],"standard_charges":[{"gross_charge":87.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-567-00","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [30070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-501-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WARFARIN 2.5 MG TABLET [8750]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-027-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-152-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-201-85","type":"NDC"}],"standard_charges":[{"gross_charge":55.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOLAZONE 2.5 MG TABLET [10587]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"76385-136-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81284-611-00","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3500-49","type":"NDC"}],"standard_charges":[{"gross_charge":30.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0169-1833-11","type":"NDC"}],"standard_charges":[{"gross_charge":14.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IV BOLUS [400293]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":3.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1559-19","type":"NDC"}],"standard_charges":[{"gross_charge":12.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MEDROXYPROGESTERONE 10 MG TABLET [4854]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0779-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-420-20","type":"NDC"}],"standard_charges":[{"gross_charge":75.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORTHALIDONE 25 MG TABLET [1661]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-167-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESIPRAMINE 25 MG TABLET [2286]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-113-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6025800615","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [122026]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-429-45","type":"NDC"}],"standard_charges":[{"gross_charge":2.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63020-049-01","type":"NDC"}],"standard_charges":[{"gross_charge":4808.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-184-10","type":"NDC"}],"standard_charges":[{"gross_charge":64.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [168096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-910-11","type":"NDC"}],"standard_charges":[{"gross_charge":195.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108122]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-781-08","type":"NDC"}],"standard_charges":[{"gross_charge":470.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLERGONOVINE 0.2 MG TABLET [10572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70010-786-28","type":"NDC"}],"standard_charges":[{"gross_charge":29.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [181236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1838-1","type":"NDC"}],"standard_charges":[{"gross_charge":276.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [104962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1154-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-38","type":"NDC"}],"standard_charges":[{"gross_charge":4.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SODIUM CHLORIDE 3 % IV BOLUS [450284]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0054-03","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 25 MCG TABLET [4420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1800-77","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6189-01","type":"NDC"}],"standard_charges":[{"gross_charge":38.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3491-94","type":"NDC"}],"standard_charges":[{"gross_charge":52.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11076]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7075-26","type":"NDC"}],"standard_charges":[{"gross_charge":7.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-476-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-306-60","type":"NDC"}],"standard_charges":[{"gross_charge":11.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET [131038]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"3932810610","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-050-11","type":"NDC"}],"standard_charges":[{"gross_charge":9.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 5 MG TABLET [36438]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-088-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [165644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57894-350-01","type":"NDC"}],"standard_charges":[{"gross_charge":5784.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-361-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [174248]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59676-575-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 10 MG TABLET [6494]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-134-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLARITHROMYCIN 500 MG TABLET [9617]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-435-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-558-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [112788]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-618-10","type":"NDC"}],"standard_charges":[{"gross_charge":215.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE-ALOE VERA NASAL GEL [127698]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0225052547","type":"NDC"}],"standard_charges":[{"gross_charge":8.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-0445-40","type":"NDC"}],"standard_charges":[{"gross_charge":0.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 160 MCG-GLYCOPYR 9 MCG-FORMOT 4.8 MCG/ACTUATION HFA INHALER [193631]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0310-4616-12","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION [119843]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1412-50","type":"NDC"}],"standard_charges":[{"gross_charge":40.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [165739]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1288-06","type":"NDC"}],"standard_charges":[{"gross_charge":5.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOTREXATE SODIUM 2.5 MG TABLET [4973]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0572-35","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10135-620-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-294-31","type":"NDC"}],"standard_charges":[{"gross_charge":11.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-914-11","type":"NDC"}],"standard_charges":[{"gross_charge":32.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-15","type":"NDC"}],"standard_charges":[{"gross_charge":107.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-615-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-170-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXCARBAZEPINE 150 MG TABLET [27049]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62756-183-88","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-185-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"66993-019-68","type":"NDC"}],"standard_charges":[{"gross_charge":88.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EZETIMIBE 10 MG TABLET [34153]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1154-3","type":"NDC"}],"standard_charges":[{"gross_charge":0.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEMETREXED DISODIUM 1,000 MG INTRAVENOUS POWDER FOR SOLUTION [199304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-148-51","type":"NDC"}],"standard_charges":[{"gross_charge":514.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [7309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3352-1","type":"NDC"}],"standard_charges":[{"gross_charge":47.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8770142510","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [124737]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9534-01","type":"NDC"}],"standard_charges":[{"gross_charge":20.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION [11403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0048-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1414-84","type":"NDC"}],"standard_charges":[{"gross_charge":28.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [113082]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0487-5901-99","type":"NDC"}],"standard_charges":[{"gross_charge":4.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6001-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6142-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BISACODYL 5 MG TABLET,DELAYED RELEASE [1079]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6407-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM [9175]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-376-35","type":"NDC"}],"standard_charges":[{"gross_charge":9.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-771-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"EZETIMIBE 10 MG TABLET [34153]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-052-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 50 MCG SPLIT TAB [450452]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-5007-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6142-0","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-7061-0","type":"NDC"}],"standard_charges":[{"gross_charge":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 10 MG TABLET [3772]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-664-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-411-12","type":"NDC"}],"standard_charges":[{"gross_charge":3.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-16","type":"NDC"}],"standard_charges":[{"gross_charge":4.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GALANTAMINE 4 MG TABLET [29806]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-729-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1264-1","type":"NDC"}],"standard_charges":[{"gross_charge":22.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-5103-1","type":"NDC"}],"standard_charges":[{"gross_charge":63.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION [119843]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1412-50","type":"NDC"}],"standard_charges":[{"gross_charge":10.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1293-83","type":"NDC"}],"standard_charges":[{"gross_charge":19.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 10 MG TABLET [10449]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0407-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-2321-06","type":"NDC"}],"standard_charges":[{"gross_charge":216.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3545-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-7516-14","type":"NDC"}],"standard_charges":[{"gross_charge":17.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7006-35","type":"NDC"}],"standard_charges":[{"gross_charge":4.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAZOLAMIDE 250 MG TABLET [113]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-054-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BALSALAZIDE 750 MG CAPSULE [29299]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-102-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYPROHEPTADINE 4 MG TABLET [2033]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-189-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-202-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-50","type":"NDC"}],"standard_charges":[{"gross_charge":13.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-614-16","type":"NDC"}],"standard_charges":[{"gross_charge":9.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-645-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE [24914]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-449-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 2.5 MG TABLET [21057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-525-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM CITRATE ORAL SOLUTION [4712]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69452-389-98","type":"NDC"}],"standard_charges":[{"gross_charge":4.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TEMAZEPAM 30 MG CAPSULE [7754]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2077-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION (PEDS) [978729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-5802-10","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [28400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0013-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0740-20","type":"NDC"}],"standard_charges":[{"gross_charge":61.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6057-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CITALOPRAM 20 MG TABLET [21062]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6085-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 200 MG TABLET [10374]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7110-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE [30961]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16571-813-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-040-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 10 MG TABLET [11110]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-665-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 10 MG TABLET [3698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-074-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 10 MG TABLET [9506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-597-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 75 MG CAPSULE [26546]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-799-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRIMIDONE 50 MG TABLET [11129]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-544-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-076-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"EPHEDRINE 5 MG/ML IV SYRINGE WRAPPER [339196]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"7811273623","type":"NDC"}],"standard_charges":[{"gross_charge":11.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81284-213-00","type":"NDC"}],"standard_charges":[{"gross_charge":49.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV [24329]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-9587-20","type":"NDC"}],"standard_charges":[{"gross_charge":42.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0043-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [121353]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9157-31","type":"NDC"}],"standard_charges":[{"gross_charge":10.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6125-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3290-91","type":"NDC"}],"standard_charges":[{"gross_charge":12.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLONIDINE HCL 0.1 MG TABLET [1755]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7442-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-282-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-216-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-15","type":"NDC"}],"standard_charges":[{"gross_charge":96.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENOFIBRATE 160 MG TABLET [28252]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-313-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-165-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59676-320-00","type":"NDC"}],"standard_charges":[{"gross_charge":968.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION [129393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60793-215-05","type":"NDC"}],"standard_charges":[{"gross_charge":182.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-368-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"NADOLOL 20 MG TABLET [5330]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-867-07","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN B COMPLEX AND VITAMIN C NO.20-FOLIC ACID 1 MG CAPSULE [38978]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6936731401","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-410-88","type":"NDC"}],"standard_charges":[{"gross_charge":15.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-0221-31","type":"NDC"}],"standard_charges":[{"gross_charge":47.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPENTOLATE 1 % EYE DROPS [2025]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0396-02","type":"NDC"}],"standard_charges":[{"gross_charge":94.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0073140106","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-53","type":"NDC"}],"standard_charges":[{"gross_charge":12.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION [1090]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1286-36","type":"NDC"}],"standard_charges":[{"gross_charge":5.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [127343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0521-76","type":"NDC"}],"standard_charges":[{"gross_charge":46.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE [11050]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904539561","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6622-61","type":"NDC"}],"standard_charges":[{"gross_charge":2.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRIMIDONE 50 MG TABLET [11129]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-686-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 325 MG TABLET,DELAYED RELEASE [685]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-921-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-TRANEXEMIC ACID INFUSION 3,000 MG/250 ML IN NS [975035]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6169-0","type":"NDC"}],"standard_charges":[{"gross_charge":58.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 2 MG TABLET [2326]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-773-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET [179625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61958-2002-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 50 MG/ML ORAL SOLUTION (FOR ORAL USE ONLY) [410309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-295-66","type":"NDC"}],"standard_charges":[{"gross_charge":76.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NITAZOXANIDE 500 MG TABLET [39254]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64980-526-60","type":"NDC"}],"standard_charges":[{"gross_charge":321.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70092-1552-07","type":"NDC"}],"standard_charges":[{"gross_charge":3.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORZOLAMIDE 2 % EYE DROPS [14471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-197-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8452176708","type":"NDC"}],"standard_charges":[{"gross_charge":3.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION [186176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-3734-13","type":"NDC"}],"standard_charges":[{"gross_charge":22642.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1761-30","type":"NDC"}],"standard_charges":[{"gross_charge":6.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"OR-KETAMINE-0.9% SODIUM CHLORIDE IV [440066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9509-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALPRAZOLAM 1 MG TABLET [326]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2031-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [25365]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3503-41","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COCAINE 4 % TOPICAL SOLUTION [339501]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0527-1728-74","type":"NDC"}],"standard_charges":[{"gross_charge":487.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [128087]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"10122-510-03","type":"NDC"}],"standard_charges":[{"gross_charge":2770.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV [131037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-641-01","type":"NDC"}],"standard_charges":[{"gross_charge":80.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP [180943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46287-006-60","type":"NDC"}],"standard_charges":[{"gross_charge":66.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYOSCYAMINE 0.125 MG/ML ORAL DROPS [3782]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54838-506-15","type":"NDC"}],"standard_charges":[{"gross_charge":56.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-198-30","type":"NDC"}],"standard_charges":[{"gross_charge":12.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-718-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-180-00","type":"NDC"}],"standard_charges":[{"gross_charge":23.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION [91651]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65649-551-02","type":"NDC"}],"standard_charges":[{"gross_charge":454.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINOCYCLINE 50 MG CAPSULE [5111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-209-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-708-95","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [181531]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-0809-01","type":"NDC"}],"standard_charges":[{"gross_charge":1375.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION [12370]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9542-01","type":"NDC"}],"standard_charges":[{"gross_charge":44.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-20","type":"NDC"}],"standard_charges":[{"gross_charge":158.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0400-37","type":"NDC"}],"standard_charges":[{"gross_charge":6.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 10 MG TABLET [9506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6717-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALAMINE 8 %-ZINC OXIDE 8 % LOTION [28055]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"1093914833","type":"NDC"}],"standard_charges":[{"gross_charge":3.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39328-063-25","type":"NDC"}],"standard_charges":[{"gross_charge":31.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [29302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42799-815-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42806-149-32","type":"NDC"}],"standard_charges":[{"gross_charge":36.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMANTADINE HCL 100 MG CAPSULE [364]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-069-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 20 MG TABLET [3294]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-072-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 50 MG TABLET [5009]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-801-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DAPSONE 25 MG TABLET [2132]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64980-567-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-855-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 250 MG TABLET [26816]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-859-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HUMAN PROTHROMBIN COMPLEX (BALFAXAR) CONCENTRATE-LANS 500 UNIT IV SOLUTION [203925]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68982-261-01","type":"NDC"}],"standard_charges":[{"gross_charge":1829.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/500 ML(10 UNIT/ML) IN 0.9 % NACL IV SOLN [131806]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-9007-53","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION [10581]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0758-01","type":"NDC"}],"standard_charges":[{"gross_charge":67.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 88 MCG TABLET [10403]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-6594-90","type":"NDC"}],"standard_charges":[{"gross_charge":4.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0078-0876-01","type":"NDC"}],"standard_charges":[{"gross_charge":722.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7510-20","type":"NDC"}],"standard_charges":[{"gross_charge":9.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-38","type":"NDC"}],"standard_charges":[{"gross_charge":4.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0675-04","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9558-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 1 % TOPICAL GEL [9623]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"21922-027-05","type":"NDC"}],"standard_charges":[{"gross_charge":17.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-007-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-437-91","type":"NDC"}],"standard_charges":[{"gross_charge":2091.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NORGESTREL 0.3 MG-ETHINYL ESTRADIOL 30 MCG TABLET [10752]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"52544-847-28","type":"NDC"}],"standard_charges":[{"gross_charge":14.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6156-0","type":"NDC"}],"standard_charges":[{"gross_charge":4.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-841-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE [27694]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-396-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-021-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIPASE-PROTEASE-AMYLASE(PORK)5,000-17,000-24,000 UNIT CAPSULE, DEL REL [186313]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"73562-115-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENOFIBRATE 160 MG TABLET [28252]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0115-5522-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2538-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SURGICAL LUBRICANT JELLY TOPICAL [123549]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0281020545","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1630-15","type":"NDC"}],"standard_charges":[{"gross_charge":27.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN B COMPLEX CAPSULE [804]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536478701","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LEVOFLOXACIN 250 MG TABLET [18918]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6351-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-478-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27241-125-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 75 MG CAPSULE [26546]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-632-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-6200-1","type":"NDC"}],"standard_charges":[{"gross_charge":44.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-750-11","type":"NDC"}],"standard_charges":[{"gross_charge":40.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG CAPSULE [9499]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-151-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION [9941]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-148-01","type":"NDC"}],"standard_charges":[{"gross_charge":190.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORPROMAZINE 25 MG TABLET [1656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-736-31","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-064-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65219-433-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69800-4203-1","type":"NDC"}],"standard_charges":[{"gross_charge":1799.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72485-409-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2540-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [121432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1160-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE [87861]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"15054-1120-4","type":"NDC"}],"standard_charges":[{"gross_charge":16199.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51144-050-01","type":"NDC"}],"standard_charges":[{"gross_charge":35253.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [190450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-207-01","type":"NDC"}],"standard_charges":[{"gross_charge":5171.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-803-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [122308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60758-908-10","type":"NDC"}],"standard_charges":[{"gross_charge":30.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV [24329]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-523-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-374-12","type":"NDC"}],"standard_charges":[{"gross_charge":8.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-433-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5216-8","type":"NDC"}],"standard_charges":[{"gross_charge":1038.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-101-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [194665]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1311-01","type":"NDC"}],"standard_charges":[{"gross_charge":544.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9554-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DEXTROSE 12.5%-SODIUM CHLORIDE 10 MEQ-POTASSIUM CHLORIDE 5 MEQ INTRAVENOUS SOLUTION (NEONATAL) [975065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7107-09","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-0201-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6238-01","type":"NDC"}],"standard_charges":[{"gross_charge":27.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM [89412]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"3010304100","type":"NDC"}],"standard_charges":[{"gross_charge":12.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"35573-428-51","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALSARTAN 80 MG TABLET [31209]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-368-09","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-775-15","type":"NDC"}],"standard_charges":[{"gross_charge":2.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-361-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-456-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 300 MG CAPSULE [18308]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-591-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-877-45","type":"NDC"}],"standard_charges":[{"gross_charge":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LURASIDONE 20 MG TABLET [113587]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-494-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6044-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS [31025]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-3218-01","type":"NDC"}],"standard_charges":[{"gross_charge":114.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0682-15","type":"NDC"}],"standard_charges":[{"gross_charge":42.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-2321-06","type":"NDC"}],"standard_charges":[{"gross_charge":216.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6773-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PERITONEAL DIALYSIS SOLN 7 (DIANEAL) DEXTR 2.5-CA 2.5 MEQ/L-MG 0.5 MEQ/L [27800]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0457-02","type":"NDC"}],"standard_charges":[{"gross_charge":162.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16714-293-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-600-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-830-60","type":"NDC"}],"standard_charges":[{"gross_charge":39.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42023-201-01","type":"NDC"}],"standard_charges":[{"gross_charge":194.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-931-11","type":"NDC"}],"standard_charges":[{"gross_charge":56.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-368-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALPRAZOLAM 0.25 MG TABLET [324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-676-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66259-146-01","type":"NDC"}],"standard_charges":[{"gross_charge":376.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINEZOLID 600 MG TABLET [28224]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-419-33","type":"NDC"}],"standard_charges":[{"gross_charge":5.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2552]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-776-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1055-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-63","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7299-73","type":"NDC"}],"standard_charges":[{"gross_charge":8.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORPROMAZINE 25 MG TABLET [1656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-0301-00","type":"NDC"}],"standard_charges":[{"gross_charge":7.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TAMSULOSIN 0.4 MG CAPSULE [103890]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7383-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOBETASOL 0.05 % TOPICAL CREAM [9630]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"21922-016-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-1000-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINERAL OIL ORAL [5086]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"48433-202-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-297-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"UREA 40 % TOPICAL CREAM [11620]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"50268-872-28","type":"NDC"}],"standard_charges":[{"gross_charge":73.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-120-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6169-0","type":"NDC"}],"standard_charges":[{"gross_charge":58.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-086-05","type":"NDC"}],"standard_charges":[{"gross_charge":23.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-78","type":"NDC"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-652-10","type":"NDC"}],"standard_charges":[{"gross_charge":48.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"67877-124-25","type":"NDC"}],"standard_charges":[{"gross_charge":20.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE 50 MG TABLET [12204]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-159-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68382-860-02","type":"NDC"}],"standard_charges":[{"gross_charge":130.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0092-65","type":"NDC"}],"standard_charges":[{"gross_charge":115.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 50 MCG TABLET [4421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-4552-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 100 MG/ML INJECTION SOLUTION [4237]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9509-01","type":"NDC"}],"standard_charges":[{"gross_charge":35.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 % MUCOSAL SPRAY [27666]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0283-0610-11","type":"NDC"}],"standard_charges":[{"gross_charge":61.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VIT A 300 MCG-C 200 MG-E 27 MG-LUTEIN 2 MG AND MINERALS TABLET [128373]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536509008","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0102-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6794-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET [8958]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6938-06","type":"NDC"}],"standard_charges":[{"gross_charge":3.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERBINAFINE HCL 1 % TOPICAL CREAM [27023]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"1093920444","type":"NDC"}],"standard_charges":[{"gross_charge":28.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-671-87","type":"NDC"}],"standard_charges":[{"gross_charge":88.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 6 MG/ML ORAL SUSPENSION [110998]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"27241-139-09","type":"NDC"}],"standard_charges":[{"gross_charge":24.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-234-10","type":"NDC"}],"standard_charges":[{"gross_charge":27.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-102-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-830-42","type":"NDC"}],"standard_charges":[{"gross_charge":26.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-350-37","type":"NDC"}],"standard_charges":[{"gross_charge":13.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-385-10","type":"NDC"}],"standard_charges":[{"gross_charge":11.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHAMBUTOL 400 MG TABLET [9983]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68850-012-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN REGULAR HUMAN U-500(CONCENTRATE) 500 UNIT/ML SUBCUTANEOUS SOLN [19180]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8501-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0049-0014-81","type":"NDC"}],"standard_charges":[{"gross_charge":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [187242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1308-01","type":"NDC"}],"standard_charges":[{"gross_charge":272.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0093-3174-31","type":"NDC"}],"standard_charges":[{"gross_charge":88.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ISOSORBIDE DINITRATE 5 MG TABLET [4068]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-1769-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9338-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3183-11","type":"NDC"}],"standard_charges":[{"gross_charge":13.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6625-02","type":"NDC"}],"standard_charges":[{"gross_charge":24.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1303-75","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6412-92","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-548-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-931-11","type":"NDC"}],"standard_charges":[{"gross_charge":56.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-743-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-454-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-16","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-671-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71399-8014-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS [5384]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0085-15","type":"NDC"}],"standard_charges":[{"gross_charge":25.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0234-20","type":"NDC"}],"standard_charges":[{"gross_charge":14.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR KIT (WRAPPER) [508005]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0078-0818-81","type":"NDC"}],"standard_charges":[{"gross_charge":12468.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION (BOLUS) [400745]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1256-28","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1362-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6059-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-405-11","type":"NDC"}],"standard_charges":[{"gross_charge":63.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-211-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-170-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"SEVELAMER CARBONATE 800 MG TABLET [89201]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-328-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-734-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-905-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROPIVACAINE(PF) 0.2 %-0.9 % SODCHL 545 ML INFIL,HI VAR RATE ELAST PUMP [188549]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71449-079-51","type":"NDC"}],"standard_charges":[{"gross_charge":990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APIXABAN 5 MG TABLET [119614]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-0894-21","type":"NDC"}],"standard_charges":[{"gross_charge":20.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [82301]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-0302-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-6001-02","type":"NDC"}],"standard_charges":[{"gross_charge":111.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [180351]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-5907-86","type":"NDC"}],"standard_charges":[{"gross_charge":8.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0581-15","type":"NDC"}],"standard_charges":[{"gross_charge":71.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 10 MG TABLET [10371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1134-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SOLUTION [181528]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2552-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-18","type":"NDC"}],"standard_charges":[{"gross_charge":2.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IRON SUCROSE 100 MG IRON/5 ML IV PUSH (WIN) [975061]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2340-01","type":"NDC"}],"standard_charges":[{"gross_charge":92.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION FOR NEBULIZATION [430038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-7604-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 325 MG TABLET [681]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1054-29","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6773-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-246-58","type":"NDC"}],"standard_charges":[{"gross_charge":859.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROXYCHLOROQUINE 200 MG TABLET [10235]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-412-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50268-745-11","type":"NDC"}],"standard_charges":[{"gross_charge":12.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-188-10","type":"NDC"}],"standard_charges":[{"gross_charge":11.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-229-01","type":"NDC"}],"standard_charges":[{"gross_charge":30.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE [40840057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9003-76","type":"NDC"}],"standard_charges":[{"gross_charge":97.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"CONJUGATED ESTROGENS 0.625 MG TABLET [9974]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0046-1102-81","type":"NDC"}],"standard_charges":[{"gross_charge":19.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9638-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4887-23","type":"NDC"}],"standard_charges":[{"gross_charge":3.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [128535]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1349-57","type":"NDC"}],"standard_charges":[{"gross_charge":6.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIGOXIN 125 MCG (0.125 MG) TABLET [2444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-590-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MELATONIN 3 MG TABLET [16830]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055503600","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLU VACCINE TS2025-26(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [212726]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-125-88","type":"NDC"}],"standard_charges":[{"gross_charge":232.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55111-678-11","type":"NDC"}],"standard_charges":[{"gross_charge":26.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [164735]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"58160-842-52","type":"NDC"}],"standard_charges":[{"gross_charge":107.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 5 MG TABLET [6497]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-122-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 5 MG TABLET [36438]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-168-11","type":"NDC"}],"standard_charges":[{"gross_charge":12.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 10 MG TABLET [5005]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-631-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SEVELAMER CARBONATE 800 MG TABLET [89201]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-058-27","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-560-99","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-784-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICARDIPINE 20 MG CAPSULE [10712]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-120-90","type":"NDC"}],"standard_charges":[{"gross_charge":8.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3475-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"HYDROXYZINE HCL 10 MG TABLET [3772]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-5060-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [10726]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1051-02","type":"NDC"}],"standard_charges":[{"gross_charge":63.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-9125-76","type":"NDC"}],"standard_charges":[{"gross_charge":14.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3365-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0591-2070-26","type":"NDC"}],"standard_charges":[{"gross_charge":19.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6125-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108130]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-192-82","type":"NDC"}],"standard_charges":[{"gross_charge":8.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6169-0","type":"NDC"}],"standard_charges":[{"gross_charge":58.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALPRAZOLAM 0.25 MG TABLET [324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-377-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-570-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 200 MG TABLET [9066]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-732-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-992-02","type":"NDC"}],"standard_charges":[{"gross_charge":23.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68462-564-17","type":"NDC"}],"standard_charges":[{"gross_charge":543.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EAR DROPS [22257]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69315-320-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-435-91","type":"NDC"}],"standard_charges":[{"gross_charge":12.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306553","type":"NDC"}],"standard_charges":[{"gross_charge":1.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INDOCYANINE GREEN 1.25 MG/ML INJECTION [632141]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-21","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE 0.2% Q PUMP [606039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4100-64","type":"NDC"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3475-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-3919-50","type":"NDC"}],"standard_charges":[{"gross_charge":1086.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0234-01","type":"NDC"}],"standard_charges":[{"gross_charge":14.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9555-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SYRINGE [124908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 6.25 MG TABLET [15747]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7306-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-10","type":"NDC"}],"standard_charges":[{"gross_charge":1031.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11074]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7074-26","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [10049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-184-82","type":"NDC"}],"standard_charges":[{"gross_charge":11.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 2.1 % (W/V), 2.0 % (W/W) ORAL SUSPENSION [18299]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-755-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"MISOPROSTOL 200 MCG TABLET [10629]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43386-161-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-145-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 125 MG TABLET,DELAYED RELEASE [2551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-211-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACLOFEN 10 MG TABLET [860]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-815-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 50 MG TABLET [3701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-734-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE 4 MG TABLET [4993]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-557-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68180-947-01","type":"NDC"}],"standard_charges":[{"gross_charge":82.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZONATATE 100 MG CAPSULE [988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69452-143-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1323-05","type":"NDC"}],"standard_charges":[{"gross_charge":14.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [181236]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0374-01","type":"NDC"}],"standard_charges":[{"gross_charge":579.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-1009-16","type":"NDC"}],"standard_charges":[{"gross_charge":47.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6836-20","type":"NDC"}],"standard_charges":[{"gross_charge":10.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-106-67","type":"NDC"}],"standard_charges":[{"gross_charge":4.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-415-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-437-10","type":"NDC"}],"standard_charges":[{"gross_charge":2091.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":99.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"INDOMETHACIN 25 MG CAPSULE [3897]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-430-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-113-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 10 MG TABLET [10371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-104-11","type":"NDC"}],"standard_charges":[{"gross_charge":10.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAZODONE 50 MG TABLET [8085]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-443-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-714-44","type":"NDC"}],"standard_charges":[{"gross_charge":2.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5216-4","type":"NDC"}],"standard_charges":[{"gross_charge":195.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70720-950-36","type":"NDC"}],"standard_charges":[{"gross_charge":2870.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-166-10","type":"NDC"}],"standard_charges":[{"gross_charge":83.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-505-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3304-1","type":"NDC"}],"standard_charges":[{"gross_charge":26.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [173831]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-5731-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0656-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-9100-76","type":"NDC"}],"standard_charges":[{"gross_charge":67.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 2.5 MG TABLET [13089]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0405-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6057-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0280-31","type":"NDC"}],"standard_charges":[{"gross_charge":7.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION [12886]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-6023-52","type":"NDC"}],"standard_charges":[{"gross_charge":199.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055504000","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALSARTAN 80 MG TABLET [31209]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42291-857-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POVIDONE-IODINE 10 % TOPICAL SWAB [27886]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"52380-4972-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"54092-189-81","type":"NDC"}],"standard_charges":[{"gross_charge":8.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE [189787]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-880-02","type":"NDC"}],"standard_charges":[{"gross_charge":3651.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-204-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"URSODIOL 300 MG CAPSULE [11624]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-421-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62935-756-80","type":"NDC"}],"standard_charges":[{"gross_charge":1140.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-77","type":"NDC"}],"standard_charges":[{"gross_charge":13.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SEVELAMER CARBONATE 800 MG TABLET [89201]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-967-93","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":0.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [17405]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0024-5926-05","type":"NDC"}],"standard_charges":[{"gross_charge":59.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0359-02","type":"NDC"}],"standard_charges":[{"gross_charge":98.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0248-01","type":"NDC"}],"standard_charges":[{"gross_charge":29.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0978-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0552-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1219-01","type":"NDC"}],"standard_charges":[{"gross_charge":32.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4777-02","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7324-66","type":"NDC"}],"standard_charges":[{"gross_charge":3.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL JELLY [4448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-711-30","type":"NDC"}],"standard_charges":[{"gross_charge":15.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-150-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-064-35","type":"NDC"}],"standard_charges":[{"gross_charge":4.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BECLOMETHASONE DIPROP 80 MCG/ACTUATION HFA BREATH ACTIVATED AEROSOL [185209]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"59310-304-80","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 10 MG TABLET [10449]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-325-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [39744]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-424-05","type":"NDC"}],"standard_charges":[{"gross_charge":9.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 10 MG TABLET [3733]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-971-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 1 % TOPICAL CREAM [3726]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-476-46","type":"NDC"}],"standard_charges":[{"gross_charge":3.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [189197]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-0404-44","type":"NDC"}],"standard_charges":[{"gross_charge":228.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDAPAMIDE 2.5 MG TABLET [3879]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0228-2571-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [9476]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-5084-13","type":"NDC"}],"standard_charges":[{"gross_charge":11.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6001-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6027-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONDANSETRON HCL 4 MG TABLET [10778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6551-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7237-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR [165559]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"10481-0112-8","type":"NDC"}],"standard_charges":[{"gross_charge":32.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-401-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TORSEMIDE 10 MG TABLET [18292]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-755-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 3.125 MG TABLET [18551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-771-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORTHALIDONE 25 MG TABLET [1661]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-317-95","type":"NDC"}],"standard_charges":[{"gross_charge":3.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-792-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-025-31","type":"NDC"}],"standard_charges":[{"gross_charge":3.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-50","type":"NDC"}],"standard_charges":[{"gross_charge":13.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-658-20","type":"NDC"}],"standard_charges":[{"gross_charge":73.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-42","type":"NDC"}],"standard_charges":[{"gross_charge":10.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0008-0923-51","type":"NDC"}],"standard_charges":[{"gross_charge":5.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FLECAINIDE 100 MG TABLET [10041]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0011-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0225-0805-47","type":"NDC"}],"standard_charges":[{"gross_charge":11.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE [7306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5534-24","type":"NDC"}],"standard_charges":[{"gross_charge":37.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6727-23","type":"NDC"}],"standard_charges":[{"gross_charge":6.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET [121502]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0972-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CITALOPRAM 10 MG TABLET [30264]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-009-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"40085-842-96","type":"NDC"}],"standard_charges":[{"gross_charge":638.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-358-03","type":"NDC"}],"standard_charges":[{"gross_charge":7.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"48433-106-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6149-0","type":"NDC"}],"standard_charges":[{"gross_charge":4.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-770-79","type":"NDC"}],"standard_charges":[{"gross_charge":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [129339]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-173-94","type":"NDC"}],"standard_charges":[{"gross_charge":4.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-464-31","type":"NDC"}],"standard_charges":[{"gross_charge":14.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-587-59","type":"NDC"}],"standard_charges":[{"gross_charge":2.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-600-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69367-264-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAZOSIN 2 MG CAPSULE [6469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-4068-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LETROZOLE 2.5 MG TABLET [21509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-7620-56","type":"NDC"}],"standard_charges":[{"gross_charge":0.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1971-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION [1312]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9180-01","type":"NDC"}],"standard_charges":[{"gross_charge":21.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA 37.5 MG-LEVODOPA 150 MG-ENTACAPONE 200 MG TABLET [36137]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-8304-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION WRAPPER [421038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-18","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4346-16","type":"NDC"}],"standard_charges":[{"gross_charge":18.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL 10 MG TABLET [3580]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-1550-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 2.5 MG TABLET [21057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6283-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEMANTINE 5 MG TABLET [37170]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6505-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [185012]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-746-03","type":"NDC"}],"standard_charges":[{"gross_charge":15.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-730-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50458-098-01","type":"NDC"}],"standard_charges":[{"gross_charge":33.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-174-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-7062-0","type":"NDC"}],"standard_charges":[{"gross_charge":3.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 250 MG TABLET [5015]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-526-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-280-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-035-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [27507]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75907-025-11","type":"NDC"}],"standard_charges":[{"gross_charge":39.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOMYCIN 500 MG TABLET [5472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-1177-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0116-1061-04","type":"NDC"}],"standard_charges":[{"gross_charge":10.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-1316-35","type":"NDC"}],"standard_charges":[{"gross_charge":44.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SYRINGE [123669]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1312-30","type":"NDC"}],"standard_charges":[{"gross_charge":6.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7293-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11077]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7077-14","type":"NDC"}],"standard_charges":[{"gross_charge":7.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 75 MG CAPSULE [26546]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-470-13","type":"NDC"}],"standard_charges":[{"gross_charge":24.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"58160-811-43","type":"NDC"}],"standard_charges":[{"gross_charge":183.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-740-24","type":"NDC"}],"standard_charges":[{"gross_charge":3.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 250 MG TABLET [20943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-742-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [191775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65597-406-01","type":"NDC"}],"standard_charges":[{"gross_charge":8128.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-424-01","type":"NDC"}],"standard_charges":[{"gross_charge":376.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM BICARBONATE 650 MG TABLET [7312]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"77333-827-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-99","type":"NDC"}],"standard_charges":[{"gross_charge":1039.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"TECHNETIUM TC99M PERTECHNATATE PER MC [450048]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9002-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0342-01","type":"NDC"}],"standard_charges":[{"gross_charge":90.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [28282]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0088-2220-33","type":"NDC"}],"standard_charges":[{"gross_charge":170.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1870-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0125-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0152-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7517-66","type":"NDC"}],"standard_charges":[{"gross_charge":40.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAZOLAMIDE 250 MG TABLET [113]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-1050-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-040-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-319-05","type":"NDC"}],"standard_charges":[{"gross_charge":7.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-211-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":99.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET [125726]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"54162-017-09","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FINASTERIDE 5 MG TABLET [10037]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-428-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-997-04","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-423-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CLINDAMYCIN HCL 150 MG CAPSULE [1740]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-243-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [28264]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-281-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-43","type":"NDC"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/10ML INJECTION SYRINGE [2848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3316-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-0213-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-0494-20","type":"NDC"}],"standard_charges":[{"gross_charge":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAMOXINE 1 % TOPICAL FOAM [19749]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0037-6823-15","type":"NDC"}],"standard_charges":[{"gross_charge":313.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-0620-40","type":"NDC"}],"standard_charges":[{"gross_charge":27.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRTAZAPINE 15 MG TABLET [17466]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-7206-56","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0807-04","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14789-134-07","type":"NDC"}],"standard_charges":[{"gross_charge":55.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"FERROUS GLUCONATE 324 MG (37.5 MG IRON) TABLET [111196]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055501900","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42571-162-42","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-436-05","type":"NDC"}],"standard_charges":[{"gross_charge":1045.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-436-90","type":"NDC"}],"standard_charges":[{"gross_charge":1045.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"},{"gross_charge":1045.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-131-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-491-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-398-01","type":"NDC"}],"standard_charges":[{"gross_charge":20.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION [169778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64764-300-20","type":"NDC"}],"standard_charges":[{"gross_charge":25999.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-438-95","type":"NDC"}],"standard_charges":[{"gross_charge":23.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [131067]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71546-003-10","type":"NDC"}],"standard_charges":[{"gross_charge":25.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-8018-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHADONE 10 MG TABLET [4953]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-5771-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE IV PUSH WRAPPER (WIN) [339404]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2310-05","type":"NDC"}],"standard_charges":[{"gross_charge":190.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [165739]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0573287194","type":"NDC"}],"standard_charges":[{"gross_charge":37.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2552]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6860-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-299-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51991-747-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-168-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION [91054]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6128-1","type":"NDC"}],"standard_charges":[{"gross_charge":83.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":5.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION [37989]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66733-958-23","type":"NDC"}],"standard_charges":[{"gross_charge":4583.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TOPIRAMATE 100 MG TABLET [18922]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-344-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-698-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-905-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-301-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-718-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [108850]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733395125","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9506-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9799]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0669-04","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-03","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-4151-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0064-01","type":"NDC"}],"standard_charges":[{"gross_charge":164.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1630-10","type":"NDC"}],"standard_charges":[{"gross_charge":26.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24338-134-02","type":"NDC"}],"standard_charges":[{"gross_charge":677.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-410-24","type":"NDC"}],"standard_charges":[{"gross_charge":8.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 25 MCG SPLIT TAB [450451]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-5007-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-405-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMITRIPTYLINE 50 MG TABLET [436]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-444-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-878-42","type":"NDC"}],"standard_charges":[{"gross_charge":2.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62559-440-02","type":"NDC"}],"standard_charges":[{"gross_charge":642.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TIMOLOL MALEATE 0.5 % EYE DROPS [11562]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64980-514-01","type":"NDC"}],"standard_charges":[{"gross_charge":39.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 100 MG TABLET [36959]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-297-06","type":"NDC"}],"standard_charges":[{"gross_charge":4.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69097-319-32","type":"NDC"}],"standard_charges":[{"gross_charge":8.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TOBRAMYCIN 0.3 % EYE DROPS [7995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-131-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NARATRIPTAN 2.5 MG TABLET [22486]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0279-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4100-90","type":"NDC"}],"standard_charges":[{"gross_charge":16.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7510-20","type":"NDC"}],"standard_charges":[{"gross_charge":9.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6015-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6228-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0781-7296-85","type":"NDC"}],"standard_charges":[{"gross_charge":45.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 500 MG TABLET [18919]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6352-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6761-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUMETANIDE 1 MG TABLET [9310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7016-61","type":"NDC"}],"standard_charges":[{"gross_charge":3.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY [16071]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16714-527-01","type":"NDC"}],"standard_charges":[{"gross_charge":108.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10050]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-184-87","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 500 MG SOLUTION FOR INJECTION [1448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-706-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-250-51","type":"NDC"}],"standard_charges":[{"gross_charge":868.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MANNITOL 25 % INTRAVENOUS SOLUTION [4750]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-024-25","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-398-14","type":"NDC"}],"standard_charges":[{"gross_charge":6.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THYROID (PORK) 30 MG TABLET [130472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69680-166-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-93","type":"NDC"}],"standard_charges":[{"gross_charge":3.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-433-91","type":"NDC"}],"standard_charges":[{"gross_charge":6.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-500-41","type":"NDC"}],"standard_charges":[{"gross_charge":7.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3505-47","type":"NDC"}],"standard_charges":[{"gross_charge":108.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MOMETASONE-FORMOTEROL HFA 100 MCG-5 MCG/ACTUATION AEROSOL INHALER [105698]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0085-7206-07","type":"NDC"}],"standard_charges":[{"gross_charge":188.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1.25 GRAM/250 ML IN DEXTROSE 5% INTRAVENOUS PIGGYBACK [206402]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0122-04","type":"NDC"}],"standard_charges":[{"gross_charge":140.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS [400297]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0125-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-0007-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIACIN 500 MG TABLET [5542]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904227260","type":"NDC"}],"standard_charges":[{"gross_charge":1.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7324-66","type":"NDC"}],"standard_charges":[{"gross_charge":3.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET [9385]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"3786400150","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZACITIDINE - SQ USE ONLY [410070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-305-62","type":"NDC"}],"standard_charges":[{"gross_charge":69.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TAMOXIFEN 10 MG TABLET [7711]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-299-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6159-0","type":"NDC"}],"standard_charges":[{"gross_charge":8.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-145-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE [5595]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-472-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-845-40","type":"NDC"}],"standard_charges":[{"gross_charge":8.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-434-41","type":"NDC"}],"standard_charges":[{"gross_charge":33.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-470-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUPHENAZINE 5 MG TABLET [3221]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1680-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/50 ML TOPICAL [632522]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0013-1114-21","type":"NDC"}],"standard_charges":[{"gross_charge":14.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION [125923]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5922-16","type":"NDC"}],"standard_charges":[{"gross_charge":27.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NAPHAZOLINE 0.02675 %-PHENIRAMINE 0.315 % EYE DROPS [15058]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"1011902090","type":"NDC"}],"standard_charges":[{"gross_charge":17.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS [2335]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-720-02","type":"NDC"}],"standard_charges":[{"gross_charge":132.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-127-20","type":"NDC"}],"standard_charges":[{"gross_charge":8.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-150-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-759-00","type":"NDC"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMITRIPTYLINE 10 MG TABLET [432]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-037-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR 400 MG TABLET [8971]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-061-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION [9080]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59651-026-75","type":"NDC"}],"standard_charges":[{"gross_charge":127.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG CAPSULE [9499]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-152-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPINIROLE 0.25 MG TABLET [21688]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-577-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-94","type":"NDC"}],"standard_charges":[{"gross_charge":1.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-486-27","type":"NDC"}],"standard_charges":[{"gross_charge":10.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARTIFICIAL TEARS OINTMENT WRAPPER [508109]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"6373614308","type":"NDC"}],"standard_charges":[{"gross_charge":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOCLOPRAMIDE 10 MG TABLET [5005]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-293-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COLCHICINE 0.6 MG TABLET [1821]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-589-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1051-3","type":"NDC"}],"standard_charges":[{"gross_charge":105.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0024-2792-01","type":"NDC"}],"standard_charges":[{"gross_charge":88.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6135-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [128535]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"3295320012","type":"NDC"}],"standard_charges":[{"gross_charge":1.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 125 MG CAPSULE [11628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42494-450-50","type":"NDC"}],"standard_charges":[{"gross_charge":1.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 25 MCG SPLIT TAB [450451]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-5007-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL 40 MG TABLET [6658]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-609-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH [117356]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63629-2064-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUCONAZOLE 100 MG TABLET [10044]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67405-602-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-433-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CETIRIZINE 10 MG TABLET [9506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-436-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IMIPRAMINE 25 MG TABLET [3861]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-134-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVONORGESTREL 1.5 MG TABLET [99445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69536-162-88","type":"NDC"}],"standard_charges":[{"gross_charge":107.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID [130903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6961800858","type":"NDC"}],"standard_charges":[{"gross_charge":21.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1530-1","type":"NDC"}],"standard_charges":[{"gross_charge":1878.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"82584-605-10","type":"NDC"}],"standard_charges":[{"gross_charge":681.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 100 MG TABLET [36959]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-0144-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0089-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1610-50","type":"NDC"}],"standard_charges":[{"gross_charge":16.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RISPERIDONE 1 MG TABLET [18313]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6359-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6761-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL OINTMENT [13651]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"16864-040-02","type":"NDC"}],"standard_charges":[{"gross_charge":37.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-424-06","type":"NDC"}],"standard_charges":[{"gross_charge":194.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-547-58","type":"NDC"}],"standard_charges":[{"gross_charge":33.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 6.25 MG TABLET [15747]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-930-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-627-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION [36591]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62856-797-01","type":"NDC"}],"standard_charges":[{"gross_charge":181.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-94","type":"NDC"}],"standard_charges":[{"gross_charge":1.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION [82200]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-00","type":"NDC"}],"standard_charges":[{"gross_charge":94.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LISINOPRIL 2.5 MG TABLET [13089]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-332-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMOTRIGINE 100 MG TABLET [13982]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-319-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-639-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION [12370]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9689-01","type":"NDC"}],"standard_charges":[{"gross_charge":27.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-20","type":"NDC"}],"standard_charges":[{"gross_charge":8.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 750 MG/150 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [108740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3580-48","type":"NDC"}],"standard_charges":[{"gross_charge":36.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0123-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IODIXANOL 270 MG IODINE/ML INTRAVENOUS SOLUTION [17594]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-2222-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ INGREDIENT ORDERABLE [425004]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-25","type":"NDC"}],"standard_charges":[{"gross_charge":17.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0241-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 10 MG TABLET [10449]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6798-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-424-25","type":"NDC"}],"standard_charges":[{"gross_charge":197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORZOLAMIDE 2 % EYE DROPS [14471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-485-10","type":"NDC"}],"standard_charges":[{"gross_charge":30.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [169280]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50419-325-37","type":"NDC"}],"standard_charges":[{"gross_charge":131.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50742-448-60","type":"NDC"}],"standard_charges":[{"gross_charge":276.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-142-31","type":"NDC"}],"standard_charges":[{"gross_charge":0.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68462-314-17","type":"NDC"}],"standard_charges":[{"gross_charge":58.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-639-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-411-80","type":"NDC"}],"standard_charges":[{"gross_charge":19.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8215-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CEVIMELINE 30 MG CAPSULE [27253]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0334-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER [421048]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-0404-44","type":"NDC"}],"standard_charges":[{"gross_charge":242.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"01439-595-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1219-01","type":"NDC"}],"standard_charges":[{"gross_charge":32.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION [3769]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4201-25","type":"NDC"}],"standard_charges":[{"gross_charge":46.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"12870-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":2.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-478-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-730-06","type":"NDC"}],"standard_charges":[{"gross_charge":82.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-387-11","type":"NDC"}],"standard_charges":[{"gross_charge":207.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-17","type":"NDC"}],"standard_charges":[{"gross_charge":10.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALPRAZOLAM 1 MG TABLET [326]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-678-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 50 MG/ML INJECTION SOLUTION [4238]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-001-00","type":"NDC"}],"standard_charges":[{"gross_charge":19.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCHLOROTHIAZIDE 12.5 MG TABLET [76988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-155-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70436-019-82","type":"NDC"}],"standard_charges":[{"gross_charge":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70710-1852-6","type":"NDC"}],"standard_charges":[{"gross_charge":600.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-505-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE [7306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5534-34","type":"NDC"}],"standard_charges":[{"gross_charge":24.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0476-21","type":"NDC"}],"standard_charges":[{"gross_charge":57.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0641-6117-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3540-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7172-07","type":"NDC"}],"standard_charges":[{"gross_charge":3.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"50484-010-30","type":"NDC"}],"standard_charges":[{"gross_charge":788.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLPIDEM 5 MG TABLET [11701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-724-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-252-20","type":"NDC"}],"standard_charges":[{"gross_charge":2.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55566-2800-0","type":"NDC"}],"standard_charges":[{"gross_charge":1393.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIGOXIN 125 MCG (0.125 MG) TABLET [2444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-540-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 100 MG CAPSULE [18309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-580-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-024-59","type":"NDC"}],"standard_charges":[{"gross_charge":4.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69680-112-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [198416]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9027-1","type":"NDC"}],"standard_charges":[{"gross_charge":69.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION [190454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"80830-2363-1","type":"NDC"}],"standard_charges":[{"gross_charge":48.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":1.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 3.5 MG/ML (0.35 %) INJECTION SOLUTION (ANE) [632140]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-20","type":"NDC"}],"standard_charges":[{"gross_charge":43.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET [121502]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0185-0842-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [11634]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-1632-21","type":"NDC"}],"standard_charges":[{"gross_charge":11.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435179750","type":"NDC"}],"standard_charges":[{"gross_charge":137.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6027-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5854-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"NORTRIPTYLINE 25 MG CAPSULE [5675]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-604-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE 10 MG TABLET [16632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-640-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 25 MG TABLET [15748]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-932-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-616-64","type":"NDC"}],"standard_charges":[{"gross_charge":2.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESCITALOPRAM 5 MG TABLET [37635]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-865-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 90 MCG/ACTUATION BREATH ACTIVATED POWDER INHALER [96976]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61269-509-06","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-044-00","type":"NDC"}],"standard_charges":[{"gross_charge":3.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-616-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-339-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-426-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMOTRIGINE 25 MG TABLET [13981]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-318-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71399-8014-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76014-004-33","type":"NDC"}],"standard_charges":[{"gross_charge":121.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [181531]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-0809-01","type":"NDC"}],"standard_charges":[{"gross_charge":1375.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [92895]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3552-48","type":"NDC"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PRAZOSIN 1 MG CAPSULE [6468]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1101-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-6470-16","type":"NDC"}],"standard_charges":[{"gross_charge":44.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3375-04","type":"NDC"}],"standard_charges":[{"gross_charge":7.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.4 MG/ML INJECTION SOLUTION WRAPPER [339300]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-1004-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PILOCARPINE 5 MG TABLET [12803]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-1313-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOBARBITAL 32.4 MG TABLET [6217]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-5166-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0121-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-164-01","type":"NDC"}],"standard_charges":[{"gross_charge":224.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-240-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"633232-367-41","type":"NDC"}],"standard_charges":[{"gross_charge":307.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR | NDC EA = 1 VIAL"}]},{"description":"LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-711-00","type":"NDC"}],"standard_charges":[{"gross_charge":166.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-002-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION [36591]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-317-25","type":"NDC"}],"standard_charges":[{"gross_charge":34.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108122]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1223-1","type":"NDC"}],"standard_charges":[{"gross_charge":471.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-163-30","type":"NDC"}],"standard_charges":[{"gross_charge":72.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-146-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1055-48","type":"NDC"}],"standard_charges":[{"gross_charge":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1215-21","type":"NDC"}],"standard_charges":[{"gross_charge":8.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3365-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-7332-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7237-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39328-034-20","type":"NDC"}],"standard_charges":[{"gross_charge":3.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 3,000 MG/100 ML TOPICAL [632523]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-1000-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BETHANECHOL CHLORIDE 10 MG TABLET [1043]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-689-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-781-11","type":"NDC"}],"standard_charges":[{"gross_charge":12.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION [129393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60793-215-05","type":"NDC"}],"standard_charges":[{"gross_charge":156.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [122308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-628-10","type":"NDC"}],"standard_charges":[{"gross_charge":11.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-94","type":"NDC"}],"standard_charges":[{"gross_charge":1.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-468-37","type":"NDC"}],"standard_charges":[{"gross_charge":33.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-613-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-494-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-051-01","type":"NDC"}],"standard_charges":[{"gross_charge":26.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70710-1531-1","type":"NDC"}],"standard_charges":[{"gross_charge":4697.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88376]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-253-01","type":"NDC"}],"standard_charges":[{"gross_charge":88.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SURGICAL LUBRICANT JELLY TOPICAL [123549]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0281020545","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-02","type":"NDC"}],"standard_charges":[{"gross_charge":30.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 5 MG TABLET [6497]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-5052-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION [31177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-6139-57","type":"NDC"}],"standard_charges":[{"gross_charge":24.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRAZODONE 50 MG TABLET [8085]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6868-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"31722-569-24","type":"NDC"}],"standard_charges":[{"gross_charge":421.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-165-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CAPTOPRIL 12.5 MG TABLET [9401]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-304-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-642-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOLIC ACID 1 MG TABLET [3233]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-681-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION [7028]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-259-30","type":"NDC"}],"standard_charges":[{"gross_charge":7.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-367-11","type":"NDC"}],"standard_charges":[{"gross_charge":14.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-421-16","type":"NDC"}],"standard_charges":[{"gross_charge":18.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN IN LACTATED RINGERS 30 UNIT/500 ML INTRAVENOUS SOLUTION [128127]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70092-1071-24","type":"NDC"}],"standard_charges":[{"gross_charge":55.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 1.25 MG/ML INJECTION [632141]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-725-01","type":"NDC"}],"standard_charges":[{"gross_charge":792.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-600-41","type":"NDC"}],"standard_charges":[{"gross_charge":0.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-437-91","type":"NDC"}],"standard_charges":[{"gross_charge":19.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306544","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0002-7597-01","type":"NDC"}],"standard_charges":[{"gross_charge":143.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-4155-73","type":"NDC"}],"standard_charges":[{"gross_charge":3.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IOHEXOL 180 MG IODINE/ML INTRATHECAL SOLUTION [10319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1411-10","type":"NDC"}],"standard_charges":[{"gross_charge":9.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"},{"gross_charge":8.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1630-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904-7734-45","type":"NDC"}],"standard_charges":[{"gross_charge":12.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"12870-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":2.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-50","type":"NDC"}],"standard_charges":[{"gross_charge":7103.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-478-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-542-02","type":"NDC"}],"standard_charges":[{"gross_charge":17.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-386-62","type":"NDC"}],"standard_charges":[{"gross_charge":41.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MONTELUKAST 10 MG TABLET [22509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-556-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108047]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-028-01","type":"NDC"}],"standard_charges":[{"gross_charge":2014.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LATANOPROST 0.005 % EYE DROPS [18621]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-547-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-142-71","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-03","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-485-27","type":"NDC"}],"standard_charges":[{"gross_charge":5.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-494-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-0623-00","type":"NDC"}],"standard_charges":[{"gross_charge":68.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0581-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMOTRIGINE ER 300 MG TABLET,EXTENDED RELEASE 24 HR [109452]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0761-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0125-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-7304-58","type":"NDC"}],"standard_charges":[{"gross_charge":5.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5854-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0955-1006-10","type":"NDC"}],"standard_charges":[{"gross_charge":35.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-473-33","type":"NDC"}],"standard_charges":[{"gross_charge":5.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL CREAM [23461]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24357-701-05","type":"NDC"}],"standard_charges":[{"gross_charge":8.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-250-51","type":"NDC"}],"standard_charges":[{"gross_charge":868.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [24559]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026886311","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-114-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEDROXYPROGESTERONE 2.5 MG TABLET [4855]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-0055-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60219-1264-1","type":"NDC"}],"standard_charges":[{"gross_charge":22.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-292-00","type":"NDC"}],"standard_charges":[{"gross_charge":18.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM CITRATE ORAL SOLUTION [4712]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70677-0051-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70710-1852-6","type":"NDC"}],"standard_charges":[{"gross_charge":600.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-435-86","type":"NDC"}],"standard_charges":[{"gross_charge":12.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE [128173]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306513","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [177829]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-4522-11","type":"NDC"}],"standard_charges":[{"gross_charge":8749.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TOBRAMYCIN 0.3 % EYE OINTMENT [19769]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0065-0644-35","type":"NDC"}],"standard_charges":[{"gross_charge":596.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10% IN WATER (D10W) IV BOLUS (NEONATAL) [450169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-03","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 750 MG/150 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [108740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3580-48","type":"NDC"}],"standard_charges":[{"gross_charge":36.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AA 5% NO.6-DEXTROSE 15%-LYTES NO.23 (CLINIMIX E 5/15) IV SOLN [27963]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-7032-01","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6015-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EYE DROPS [19746]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"11980-779-05","type":"NDC"}],"standard_charges":[{"gross_charge":343.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMOTRIGINE 100 MG TABLET [13982]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-701-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL JELLY [4448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-711-30","type":"NDC"}],"standard_charges":[{"gross_charge":15.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-259-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE MALEATE 10 MG TABLET [6582]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-685-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2116-0","type":"NDC"}],"standard_charges":[{"gross_charge":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PHENYTOIN SODIUM EXTENDED 300 MG CAPSULE [31945]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62756-432-83","type":"NDC"}],"standard_charges":[{"gross_charge":5.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-750-95","type":"NDC"}],"standard_charges":[{"gross_charge":1.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-910-01","type":"NDC"}],"standard_charges":[{"gross_charge":31.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-0213-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0013-1114-20","type":"NDC"}],"standard_charges":[{"gross_charge":12.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGIC MOUTHWASH ORAL SOLUTION [975049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0489-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9786-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-5535-32","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GUANFACINE 1 MG TABLET [10149]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1160-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6625-22","type":"NDC"}],"standard_charges":[{"gross_charge":24.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [27506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-3509-54","type":"NDC"}],"standard_charges":[{"gross_charge":44.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6013-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6773-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [212730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"19515-904-41","type":"NDC"}],"standard_charges":[{"gross_charge":57.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55111-680-11","type":"NDC"}],"standard_charges":[{"gross_charge":80.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-558-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-718-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1642-1","type":"NDC"}],"standard_charges":[{"gross_charge":55.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [116842]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70710-1159-9","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICAFUNGIN 100 MG INTRAVENOUS SOLUTION [77685]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-029-10","type":"NDC"}],"standard_charges":[{"gross_charge":69.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306544","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-6780-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE [165310]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-04","type":"NDC"}],"standard_charges":[{"gross_charge":7.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4887-24","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6727-23","type":"NDC"}],"standard_charges":[{"gross_charge":6.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 3 % FOR NEBULIZATION [7327]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487900360","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 5 % EYE DROPS [7332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1254-94","type":"NDC"}],"standard_charges":[{"gross_charge":10.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0536-1263-28","type":"NDC"}],"standard_charges":[{"gross_charge":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BRIMONIDINE 0.2 % EYE DROPS [17881]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-411-05","type":"NDC"}],"standard_charges":[{"gross_charge":40.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-458-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-113-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 50 MG/ML INJECTION SOLUTION [4238]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-439-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 0.5 MG TABLET [4572]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-627-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIGOXIN 125 MCG (0.125 MG) TABLET [2444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-858-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-485-57","type":"NDC"}],"standard_charges":[{"gross_charge":17.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALTREXONE 50 MG TABLET [10685]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-291-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MODAFINIL 100 MG TABLET [24702]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-621-11","type":"NDC"}],"standard_charges":[{"gross_charge":12.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-600-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [25246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-4161-76","type":"NDC"}],"standard_charges":[{"gross_charge":10.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION [10577]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9851-01","type":"NDC"}],"standard_charges":[{"gross_charge":104.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIGOXIN 125 MCG (0.125 MG) TABLET [2444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5921-61","type":"NDC"}],"standard_charges":[{"gross_charge":2.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-12","type":"NDC"}],"standard_charges":[{"gross_charge":4124.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [165400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-189-01","type":"NDC"}],"standard_charges":[{"gross_charge":98.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"45802-410-59","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-144-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MECLIZINE 12.5 MG TABLET [12024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-522-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"RIVAROXABAN 10 MG TABLET [110250]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50458-580-01","type":"NDC"}],"standard_charges":[{"gross_charge":37.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLUCOSE CHEWABLE TABLET 4 G (TOT 4 G CHO) [16050]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"56151-1610-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 5 MG TABLET [6497]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60219-1706-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-0823-6","type":"NDC"}],"standard_charges":[{"gross_charge":184.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COLCHICINE 0.6 MG TABLET [1821]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-727-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-614-00","type":"NDC"}],"standard_charges":[{"gross_charge":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67850-022-00","type":"NDC"}],"standard_charges":[{"gross_charge":13.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-783-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72888-125-26","type":"NDC"}],"standard_charges":[{"gross_charge":26.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-302-43","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHADONE 5 MG TABLET [4954]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0709-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7751-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-06","type":"NDC"}],"standard_charges":[{"gross_charge":9.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZTROPINE 1 MG TABLET [999]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-2434-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3407-78","type":"NDC"}],"standard_charges":[{"gross_charge":2.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR [9773]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6312-56","type":"NDC"}],"standard_charges":[{"gross_charge":14.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOBARBITAL 16.2 MG TABLET [6215]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16571-671-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOBUNOLOL 0.5 % EYE DROPS [10394]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-505-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-282-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET [11218]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"37000-024-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [108096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-262-11","type":"NDC"}],"standard_charges":[{"gross_charge":146.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-439-93","type":"NDC"}],"standard_charges":[{"gross_charge":8365.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-775-15","type":"NDC"}],"standard_charges":[{"gross_charge":2.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2116-4","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-70","type":"NDC"}],"standard_charges":[{"gross_charge":5.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1.25 GRAM/250 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [131039]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-341-05","type":"NDC"}],"standard_charges":[{"gross_charge":141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-246-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL 4 MG TABLET [10778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-220-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET [8958]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-1787-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1209-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [165023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1660-10","type":"NDC"}],"standard_charges":[{"gross_charge":132.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK [164873]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-826-82","type":"NDC"}],"standard_charges":[{"gross_charge":123.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"39822-3050-2","type":"NDC"}],"standard_charges":[{"gross_charge":249.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-305-62","type":"NDC"}],"standard_charges":[{"gross_charge":69.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-580-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-732-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"},{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-303-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"61269-220-41","type":"NDC"}],"standard_charges":[{"gross_charge":13.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-309-06","type":"NDC"}],"standard_charges":[{"gross_charge":19.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-474-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-483-03","type":"NDC"}],"standard_charges":[{"gross_charge":12.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 25 MG TABLET [15748]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-152-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"69097-142-60","type":"NDC"}],"standard_charges":[{"gross_charge":48.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70095-050-01","type":"NDC"}],"standard_charges":[{"gross_charge":14.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-4681-01","type":"NDC"}],"standard_charges":[{"gross_charge":251.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [130944]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0011-03","type":"NDC"}],"standard_charges":[{"gross_charge":57.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0049-0520-84","type":"NDC"}],"standard_charges":[{"gross_charge":12.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 500 MG/100ML ENEMA [480289]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-4332-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 1 MEQ/ML ORAL SOLUTION [975042]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6657-01","type":"NDC"}],"standard_charges":[{"gross_charge":72.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0121-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6231-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7252-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-294-31","type":"NDC"}],"standard_charges":[{"gross_charge":11.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"52268-100-01","type":"NDC"}],"standard_charges":[{"gross_charge":72.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-221-01","type":"NDC"}],"standard_charges":[{"gross_charge":7512.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-185-07","type":"NDC"}],"standard_charges":[{"gross_charge":2.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PACLITAXEL PROTEIN-BOUND 100 MG INTRAVENOUS SUSPENSION [40475]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68817-134-50","type":"NDC"}],"standard_charges":[{"gross_charge":4574.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET [131038]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6954325810","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-411-80","type":"NDC"}],"standard_charges":[{"gross_charge":19.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72485-201-01","type":"NDC"}],"standard_charges":[{"gross_charge":87.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARFILZOMIB 30 MG INTRAVENOUS SOLUTION [180437]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"76075-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":4714.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-0856-05","type":"NDC"}],"standard_charges":[{"gross_charge":221.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-0418-24","type":"NDC"}],"standard_charges":[{"gross_charge":2.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35942]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5317-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN IV SYRINGE 5 MG/ML IN D5W (PEDIATRIC) (PREMIX) [981033]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3551-48","type":"NDC"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [121784]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3059-72","type":"NDC"}],"standard_charges":[{"gross_charge":7.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 300 MG CAPSULE [18308]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6666-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 200 MG TABLET [3841]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7914-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":24.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-122-67","type":"NDC"}],"standard_charges":[{"gross_charge":16.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 10 MG TABLET [34369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-179-11","type":"NDC"}],"standard_charges":[{"gross_charge":12.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PYRAZINAMIDE 500 MG TABLET [6738]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61748-012-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-27","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 1 MG/ML INJECTION SOLUTION [121831]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-852-03","type":"NDC"}],"standard_charges":[{"gross_charge":8.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-483-46","type":"NDC"}],"standard_charges":[{"gross_charge":4.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68462-469-40","type":"NDC"}],"standard_charges":[{"gross_charge":6.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL [194797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-6290-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-93","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [130756]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0047-25","type":"NDC"}],"standard_charges":[{"gross_charge":23.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3073-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9320-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9873-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-5535-32","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3612-50","type":"NDC"}],"standard_charges":[{"gross_charge":29.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [9476]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-5084-13","type":"NDC"}],"standard_charges":[{"gross_charge":11.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ANASTROZOLE 1 MG TABLET [16205]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-035-15","type":"NDC"}],"standard_charges":[{"gross_charge":0.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-009-24","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":99.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CILOSTAZOL 100 MG TABLET [24474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-177-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-684-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-614-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-002-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-424-01","type":"NDC"}],"standard_charges":[{"gross_charge":376.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1049-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYLEPHRINE 0.4 MG/10 ML (40 MCG/ML) IN 0.9 %SOD.CHLORIDE IV SYRINGE [131065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71506-040-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71656-021-15","type":"NDC"}],"standard_charges":[{"gross_charge":9.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIPASE-PROTEASE-AMYLASE(PORK)5,000-17,000-24,000 UNIT CAPSULE, DEL REL [186313]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-6115-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [190842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0126-12","type":"NDC"}],"standard_charges":[{"gross_charge":55.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1886-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COMPOUNDING VEHICLE SUSPENSION NO.19 ORAL [176682]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574031116","type":"NDC"}],"standard_charges":[{"gross_charge":39.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6253-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7252-80","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10019-553-90","type":"NDC"}],"standard_charges":[{"gross_charge":52.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POVIDONE-IODINE 10 % TOPICAL SWAB [27886]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10819-3888-2","type":"NDC"}],"standard_charges":[{"gross_charge":1.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":20.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"4110081125","type":"NDC"}],"standard_charges":[{"gross_charge":52.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-446-71","type":"NDC"}],"standard_charges":[{"gross_charge":4.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-820-01","type":"NDC"}],"standard_charges":[{"gross_charge":48.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-054-35","type":"NDC"}],"standard_charges":[{"gross_charge":8.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-771-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51754-0203-2","type":"NDC"}],"standard_charges":[{"gross_charge":19.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-116-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [190450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-206-01","type":"NDC"}],"standard_charges":[{"gross_charge":1292.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-339-50","type":"NDC"}],"standard_charges":[{"gross_charge":130.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 12.5% IN WATER (D12.5W) INTRAVENOUS SOLUTION (WIN) [606203]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4003-63","type":"NDC"}],"standard_charges":[{"gross_charge":150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8315-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RASBURICASE 1.5 MG INTRAVENOUS SOLUTION [33591]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0024-5150-10","type":"NDC"}],"standard_charges":[{"gross_charge":3223.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0209-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MUPIROCIN 2 % TOPICAL OINTMENT [10674]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0093-1010-42","type":"NDC"}],"standard_charges":[{"gross_charge":25.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-4839-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACOSAMIDE 50 MG TABLET [96968]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0131-2477-35","type":"NDC"}],"standard_charges":[{"gross_charge":33.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION [11403]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0048-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0960-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION [131499]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2310-05","type":"NDC"}],"standard_charges":[{"gross_charge":190.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ESCITALOPRAM 10 MG TABLET [33512]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6426-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET [125887]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42806-270-98","type":"NDC"}],"standard_charges":[{"gross_charge":2.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-400-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SPIRONOLACTONE 25 MG TABLET [7437]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-103-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN 2 % TOPICAL OINTMENT [10674]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1312-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-2114-2","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57894-160-01","type":"NDC"}],"standard_charges":[{"gross_charge":1316.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-442-24","type":"NDC"}],"standard_charges":[{"gross_charge":33.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CELLULOSE, OXIDIZED 4\" X 8\" PADS [632122]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-4001-14","type":"NDC"}],"standard_charges":[{"gross_charge":1.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 PACKAGE"}]},{"description":"NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0281-0326-08","type":"NDC"}],"standard_charges":[{"gross_charge":6.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0094-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0123-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0713-0351-02","type":"NDC"}],"standard_charges":[{"gross_charge":12.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7237-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-1000-1","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [28643]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-597-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BREXPIPRAZOLE 1 MG TABLET [176051]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59148-037-13","type":"NDC"}],"standard_charges":[{"gross_charge":111.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZIPRASIDONE 20 MG CAPSULE [29778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-2528-6","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-622-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VILAZODONE 20 MG TABLET [109403]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-233-30","type":"NDC"}],"standard_charges":[{"gross_charge":2.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-645-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG TABLET [17937]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-740-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN 2 % TOPICAL OINTMENT [10674]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68462-180-22","type":"NDC"}],"standard_charges":[{"gross_charge":14.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [193630]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"75907-190-07","type":"NDC"}],"standard_charges":[{"gross_charge":623.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NITROGLYCERIN 250 MCG/2.5 ML (100 MCG/ML) IV [480086]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-9007-83","type":"NDC"}],"standard_charges":[{"gross_charge":0.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 1 % TOPICAL CREAM [3726]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0015-31","type":"NDC"}],"standard_charges":[{"gross_charge":14.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7610-10","type":"NDC"}],"standard_charges":[{"gross_charge":11.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9801]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0671-04","type":"NDC"}],"standard_charges":[{"gross_charge":7.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"QUETIAPINE 25 MG TABLET [21823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6638-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 200 MG TABLET [3841]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7914-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-420-00","type":"NDC"}],"standard_charges":[{"gross_charge":18.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-381-11","type":"NDC"}],"standard_charges":[{"gross_charge":133.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOZAPINE 25 MG TABLET [9648]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-404-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-128-00","type":"NDC"}],"standard_charges":[{"gross_charge":18.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-22","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-464-31","type":"NDC"}],"standard_charges":[{"gross_charge":14.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [1635]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-478-27","type":"NDC"}],"standard_charges":[{"gross_charge":46.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-553-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68001-265-23","type":"NDC"}],"standard_charges":[{"gross_charge":129.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYTOCIN IN LACTATED RINGERS 30 UNIT/500 ML INTRAVENOUS SOLUTION [128127]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70092-1071-24","type":"NDC"}],"standard_charges":[{"gross_charge":55.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72485-510-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"72485-670-31","type":"NDC"}],"standard_charges":[{"gross_charge":25.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0795-15","type":"NDC"}],"standard_charges":[{"gross_charge":10.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9156-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY [19696]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0283-0679-02","type":"NDC"}],"standard_charges":[{"gross_charge":88.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSIMERTINIB 80 MG TABLET [177168]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0310-1350-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS IV BOLUS [400296]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [167938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE [7306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5534-34","type":"NDC"}],"standard_charges":[{"gross_charge":24.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0031-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1874-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 100 MG CAPSULE [2566]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6998-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-415-01","type":"NDC"}],"standard_charges":[{"gross_charge":52.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAPSAICIN 0.025 % TOPICAL CREAM [1350]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"50268-195-60","type":"NDC"}],"standard_charges":[{"gross_charge":10.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [78064]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50458-550-01","type":"NDC"}],"standard_charges":[{"gross_charge":36.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 5 % TOPICAL CREAM [10065]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-4118-6","type":"NDC"}],"standard_charges":[{"gross_charge":60.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-188-10","type":"NDC"}],"standard_charges":[{"gross_charge":16.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-252-20","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-992-02","type":"NDC"}],"standard_charges":[{"gross_charge":23.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 20 MG TABLET [11111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-196-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [169676]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-7669-01","type":"NDC"}],"standard_charges":[{"gross_charge":4284.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RALTEGRAVIR 400 MG TABLET [88608]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-0227-61","type":"NDC"}],"standard_charges":[{"gross_charge":97.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAXOLOL 0.25 % EYE DROPS,SUSPENSION [19703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0078-0729-10","type":"NDC"}],"standard_charges":[{"gross_charge":1078.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9570-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [187729]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0310-1105-01","type":"NDC"}],"standard_charges":[{"gross_charge":59.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 3 % FOR NEBULIZATION [7327]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0378699789","type":"NDC"}],"standard_charges":[{"gross_charge":5.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4777-02","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6629-12","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6450-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EYE DROPS [19746]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"11980-779-05","type":"NDC"}],"standard_charges":[{"gross_charge":343.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-165-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-167-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-173-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-94","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIFAXIMIN 550 MG TABLET [104604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65649-303-03","type":"NDC"}],"standard_charges":[{"gross_charge":162.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-528-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXAZOSIN 1 MG TABLET [9894]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-836-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET [94158]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"77333-844-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INSULIN NPH-REGULAR 70-30 MIX 100 UNIT/ML (U-100) SUBCUTANEOUS SUSP [10286]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8715-17","type":"NDC"}],"standard_charges":[{"gross_charge":1.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0800-50","type":"NDC"}],"standard_charges":[{"gross_charge":166.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0209-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 25 MG TABLET [3700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-520-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-252-51","type":"NDC"}],"standard_charges":[{"gross_charge":1010.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"RUXOLITINIB 20 MG TABLET [112939]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50881-020-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION [18877]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-252-40","type":"NDC"}],"standard_charges":[{"gross_charge":27.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DONEPEZIL 5 MG TABLET [18786]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-292-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-406-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE [12184]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-466-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-884-44","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-434-41","type":"NDC"}],"standard_charges":[{"gross_charge":33.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-700-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE 20 MG TABLET [10855]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-045-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATORVASTATIN 10 MG TABLET [19176]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-097-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-587-59","type":"NDC"}],"standard_charges":[{"gross_charge":2.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1642-1","type":"NDC"}],"standard_charges":[{"gross_charge":55.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76297-001-32","type":"NDC"}],"standard_charges":[{"gross_charge":15.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET [1308]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8068114000","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0868-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION WRAPPER [425002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9331-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM BICARBONATE 325 MG TABLET [7311]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0223-1720-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS IV BOLUS [400296]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6014-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-2725-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEMETREXED DISODIUM 1,000 MG INTRAVENOUS POWDER FOR SOLUTION [199304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-370-74","type":"NDC"}],"standard_charges":[{"gross_charge":415.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROCORTISONE 1 % TOPICAL OINTMENT [3731]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"45802-276-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50268-745-14","type":"NDC"}],"standard_charges":[{"gross_charge":13.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50742-505-01","type":"NDC"}],"standard_charges":[{"gross_charge":25.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ATENOLOL 50 MG TABLET [718]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-684-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-119-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-35","type":"NDC"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-367-11","type":"NDC"}],"standard_charges":[{"gross_charge":14.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-411-12","type":"NDC"}],"standard_charges":[{"gross_charge":3.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [113060]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-649-07","type":"NDC"}],"standard_charges":[{"gross_charge":311.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG CAPSULE [10070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-400-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-613-04","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 1 % LOTION [3728]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0039485932","type":"NDC"}],"standard_charges":[{"gross_charge":23.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0186-1988-04","type":"NDC"}],"standard_charges":[{"gross_charge":24.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11077]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0703-41","type":"NDC"}],"standard_charges":[{"gross_charge":7.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE 0.125% EPIDURAL [400818]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1165-02","type":"NDC"}],"standard_charges":[{"gross_charge":10.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION FOR NEBULIZATION [430038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-7604-25","type":"NDC"}],"standard_charges":[{"gross_charge":35.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6019-01","type":"NDC"}],"standard_charges":[{"gross_charge":56.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-705-87","type":"NDC"}],"standard_charges":[{"gross_charge":24.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-491-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-644-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TAMOXIFEN 10 MG TABLET [7711]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51862-642-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET [125726]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-111-09","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":12.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [169752]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63833-396-01","type":"NDC"}],"standard_charges":[{"gross_charge":2953.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIOTHYRONINE 5 MCG TABLET [10443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-582-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCHLOROTHIAZIDE 12.5 MG TABLET [76988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-155-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FERROUS SULFATE ORAL DROPS 15 MG IRON (75 MG)/ML [632150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"7139974805","type":"NDC"}],"standard_charges":[{"gross_charge":167.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VILAZODONE 20 MG TABLET [109403]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72205-261-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [19596]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"82667-600-05","type":"NDC"}],"standard_charges":[{"gross_charge":191.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.65 % NASAL DROPS [18225]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0225055050","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-41","type":"NDC"}],"standard_charges":[{"gross_charge":3.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0089-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 100 MG CAPSULE [24500]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-7160-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLUCAGON HCL 1 MG/ML INJECTION WRAPPER [339421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0548-5850-00","type":"NDC"}],"standard_charges":[{"gross_charge":526.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHACRYNIC ACID 25 MG TABLET [9980]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-1690-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG TABLET [11349]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6522-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24201-201-01","type":"NDC"}],"standard_charges":[{"gross_charge":199.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":99.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CYCLOBENZAPRINE 10 MG TABLET [2017]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-644-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6148-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6149-0","type":"NDC"}],"standard_charges":[{"gross_charge":4.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 100 MG CAPSULE [24500]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-436-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXAZEPAM 15 MG CAPSULE [5931]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-813-11","type":"NDC"}],"standard_charges":[{"gross_charge":5.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-421-16","type":"NDC"}],"standard_charges":[{"gross_charge":18.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION [169778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64764-300-20","type":"NDC"}],"standard_charges":[{"gross_charge":26271.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROMETHAZINE 25 MG TABLET [6622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-155-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LOSARTAN 25 MG TABLET [14823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-346-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [196862]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0005-2000-02","type":"NDC"}],"standard_charges":[{"gross_charge":658.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3410-24","type":"NDC"}],"standard_charges":[{"gross_charge":19.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION WRAPPER [425002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1162-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 10 MG/ML INJECTION SOLUTION (WRAPPER) [975234]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6127-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-25","type":"NDC"}],"standard_charges":[{"gross_charge":26.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-931-11","type":"NDC"}],"standard_charges":[{"gross_charge":56.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10 %-PRO-IGA 0 TO 50 MCG/ML IV SOLN [175231]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-437-91","type":"NDC"}],"standard_charges":[{"gross_charge":2091.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-820-01","type":"NDC"}],"standard_charges":[{"gross_charge":48.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-184-10","type":"NDC"}],"standard_charges":[{"gross_charge":63.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-186-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-27","type":"NDC"}],"standard_charges":[{"gross_charge":8.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE [15339]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-279-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETHACRYNIC ACID 25 MG TABLET [9980]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68682-011-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-41","type":"NDC"}],"standard_charges":[{"gross_charge":8.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET [2012]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733393725","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [177829]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-4522-11","type":"NDC"}],"standard_charges":[{"gross_charge":8749.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CLOTRIMAZOLE 10 MG TROCHE [9644]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-4146-22","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9606-01","type":"NDC"}],"standard_charges":[{"gross_charge":69.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-1800-32","type":"NDC"}],"standard_charges":[{"gross_charge":7.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IV BOLUS [400293]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-04","type":"NDC"}],"standard_charges":[{"gross_charge":4.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1778-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7084-04","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-101-67","type":"NDC"}],"standard_charges":[{"gross_charge":2.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"46122-440-78","type":"NDC"}],"standard_charges":[{"gross_charge":0.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-714-44","type":"NDC"}],"standard_charges":[{"gross_charge":2.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-27","type":"NDC"}],"standard_charges":[{"gross_charge":15.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARTIFICIAL TEARS OINTMENT WRAPPER [508109]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"6373614308","type":"NDC"}],"standard_charges":[{"gross_charge":18.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-163-02","type":"NDC"}],"standard_charges":[{"gross_charge":182.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-910-01","type":"NDC"}],"standard_charges":[{"gross_charge":38.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69339-136-03","type":"NDC"}],"standard_charges":[{"gross_charge":40.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81033-002-20","type":"NDC"}],"standard_charges":[{"gross_charge":2.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9506-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION [12370]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9689-10","type":"NDC"}],"standard_charges":[{"gross_charge":25.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SYRINGE [124908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-03","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9904-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PERITONEAL DIALYSIS SOLN 7 (DIANEAL) DEXTR 2.5-CA 2.5 MEQ/L-MG 0.5 MEQ/L [27800]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0430-52","type":"NDC"}],"standard_charges":[{"gross_charge":90.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 4 % EYE DROPS [6282]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0998-0206-15","type":"NDC"}],"standard_charges":[{"gross_charge":279.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-298-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION WRAPPER [421038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-600-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-688-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"46122-352-74","type":"NDC"}],"standard_charges":[{"gross_charge":3.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 50 MCG SPLIT TAB [450452]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-5007-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BRIMONIDINE 0.1 % EYE DROPS [70262]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-0577-1","type":"NDC"}],"standard_charges":[{"gross_charge":491.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-457-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-26","type":"NDC"}],"standard_charges":[{"gross_charge":0.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-485-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC OXIDE 20 % TOPICAL OINTMENT [8874]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-532-46","type":"NDC"}],"standard_charges":[{"gross_charge":12.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IMIPRAMINE 50 MG TABLET [3862]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69584-427-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0544-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-4827-05","type":"NDC"}],"standard_charges":[{"gross_charge":11.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-63","type":"NDC"}],"standard_charges":[{"gross_charge":0.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9501-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0159-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6027-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3000-94","type":"NDC"}],"standard_charges":[{"gross_charge":25.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7293-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUSPIRONE 5 MG TABLET [9324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"29300-244-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-01","type":"NDC"}],"standard_charges":[{"gross_charge":30.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THYROID (PORK) 15 MG TABLET [130471]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42192-327-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-150-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47781-491-50","type":"NDC"}],"standard_charges":[{"gross_charge":3.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-395-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 200 MG TABLET [9066]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-437-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70954-518-10","type":"NDC"}],"standard_charges":[{"gross_charge":65.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL-ROPIVACAINE-NACL (PF) 2 MCG/ML-0.1% EPIDURAL SOLUTION [127945]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"9999-9999-47","type":"NDC"}],"standard_charges":[{"gross_charge":104.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0008-0844-01","type":"NDC"}],"standard_charges":[{"gross_charge":39.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCRALFATE 1 GRAM TABLET [11442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-2210-98","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9511-01","type":"NDC"}],"standard_charges":[{"gross_charge":103.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"GENTAMICIN IV SYRINGE 2 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450420]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0511-41","type":"NDC"}],"standard_charges":[{"gross_charge":6.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 5 MG/ML INJECTION SOLUTION [10608]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2596-05","type":"NDC"}],"standard_charges":[{"gross_charge":16.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6729-03","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 1 MG/ML ORAL SOLUTION [975013]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9158-01","type":"NDC"}],"standard_charges":[{"gross_charge":97.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMILORIDE 5 MG TABLET [391]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0574-0292-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-937-05","type":"NDC"}],"standard_charges":[{"gross_charge":7.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 1 MG TABLET [9310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42799-120-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-007-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TEMAZEPAM 15 MG CAPSULE [7753]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-779-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-142-31","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-325-20","type":"NDC"}],"standard_charges":[{"gross_charge":97.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-REMIFENTANIL-0.9% SODIUM CHLORIDE IV [440045]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-198-00","type":"NDC"}],"standard_charges":[{"gross_charge":111.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-339-50","type":"NDC"}],"standard_charges":[{"gross_charge":4.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1574-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"7811201103","type":"NDC"}],"standard_charges":[{"gross_charge":13.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [173958]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0006-3026-01","type":"NDC"}],"standard_charges":[{"gross_charge":16672.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREDNISONE 10 MG TABLET [6494]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0017-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4400-54","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0553-11","type":"NDC"}],"standard_charges":[{"gross_charge":8.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4888-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6794-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-631-10","type":"NDC"}],"standard_charges":[{"gross_charge":212.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-252-51","type":"NDC"}],"standard_charges":[{"gross_charge":1001.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [3071]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5026833611","type":"NDC"}],"standard_charges":[{"gross_charge":8.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 25 MG TABLET [3700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-075-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6149-0","type":"NDC"}],"standard_charges":[{"gross_charge":4.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-795-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ISOSORBIDE DINITRATE 10 MG TABLET [4064]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-082-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-421-07","type":"NDC"}],"standard_charges":[{"gross_charge":0.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-301-01","type":"NDC"}],"standard_charges":[{"gross_charge":22.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81033-412-15","type":"NDC"}],"standard_charges":[{"gross_charge":6.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 325 MG TABLET [681]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0113-0416-78","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0043-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1273-32","type":"NDC"}],"standard_charges":[{"gross_charge":87.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SOLUTION [181528]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2552-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7193-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [125727]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-060-70","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFPROZIL 125 MG/5 ML ORAL SUSPENSION [9470]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57237-034-75","type":"NDC"}],"standard_charges":[{"gross_charge":93.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION [193242]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61958-2901-2","type":"NDC"}],"standard_charges":[{"gross_charge":1848.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62584-693-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-201-02","type":"NDC"}],"standard_charges":[{"gross_charge":7.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN, PORCINE (PF) 100 UNIT/ML (1 ML) INTRAVENOUS SOLUTION [128177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6332354901","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 1 MG/ML ORAL SOLUTION WRAPPER [421036]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-004-59","type":"NDC"}],"standard_charges":[{"gross_charge":5.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-783-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR [32631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72241-029-22","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72578-064-14","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE, MICROSPHERES 10 MG INTRAMUSCULAR KIT (WRAPPER) [508004]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0078-0811-81","type":"NDC"}],"standard_charges":[{"gross_charge":9500.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OR-FENTANYL-0.9% SODIUM CHLORIDE IV [440067]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9093-45","type":"NDC"}],"standard_charges":[{"gross_charge":0.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1852-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1874-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROCORTISONE 5 MG TABLET [10209]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-405-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 300 MG TABLET [311]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-206-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION [191669]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-223-01","type":"NDC"}],"standard_charges":[{"gross_charge":3796.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-870-44","type":"NDC"}],"standard_charges":[{"gross_charge":12.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL IV INJECTION [410075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-51","type":"NDC"}],"standard_charges":[{"gross_charge":40.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [168096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-910-11","type":"NDC"}],"standard_charges":[{"gross_charge":180.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALACYCLOVIR 500 MG TABLET [13133]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-077-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET [130560]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6498012950","type":"NDC"}],"standard_charges":[{"gross_charge":0.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LOSARTAN 25 MG TABLET [14823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-201-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-182-00","type":"NDC"}],"standard_charges":[{"gross_charge":17.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [9502]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68180-441-01","type":"NDC"}],"standard_charges":[{"gross_charge":63.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70000-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":10.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-42","type":"NDC"}],"standard_charges":[{"gross_charge":10.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-160-10","type":"NDC"}],"standard_charges":[{"gross_charge":27.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-3663-03","type":"NDC"}],"standard_charges":[{"gross_charge":12821.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9320-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7750-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [92895]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3552-48","type":"NDC"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-8020-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1362-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [11359]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"12870-0001-2","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"VARENICLINE TARTRATE 0.5 MG TABLET [76444]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27241-173-56","type":"NDC"}],"standard_charges":[{"gross_charge":2.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION [1090]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"46122-703-26","type":"NDC"}],"standard_charges":[{"gross_charge":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-557-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAPPER [339544]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-795-16","type":"NDC"}],"standard_charges":[{"gross_charge":17.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-532-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION [37848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-417-44","type":"NDC"}],"standard_charges":[{"gross_charge":12.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE 0.125% NERVE CATHETER [606037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-464-31","type":"NDC"}],"standard_charges":[{"gross_charge":21.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6498033990","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [119149]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-714-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"THIAMINE (VITAMIN B1) 100 MG TABLET (WRAPPER) [508008]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733393425","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE [128173]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306424","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9564-01","type":"NDC"}],"standard_charges":[{"gross_charge":1289.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDODRINE 2.5 MG TABLET [10609]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-0211-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-41","type":"NDC"}],"standard_charges":[{"gross_charge":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104565]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-9321-32","type":"NDC"}],"standard_charges":[{"gross_charge":0.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1886-22","type":"NDC"}],"standard_charges":[{"gross_charge":5.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1228-58","type":"NDC"}],"standard_charges":[{"gross_charge":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-5894-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ATORVASTATIN 40 MG TABLET [19177]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6292-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMITRIPTYLINE 10 MG TABLET [432]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"29300-419-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BICALUTAMIDE 50 MG TABLET [15746]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47335-485-83","type":"NDC"}],"standard_charges":[{"gross_charge":1.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [128574]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"54288-103-01","type":"NDC"}],"standard_charges":[{"gross_charge":24.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-017-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN A AND D TOPICAL OINTMENT [15283]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"57896-112-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM [128535]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"57896-116-03","type":"NDC"}],"standard_charges":[{"gross_charge":8.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-16","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-494-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-299-00","type":"NDC"}],"standard_charges":[{"gross_charge":110.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3469-1","type":"NDC"}],"standard_charges":[{"gross_charge":74.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"78206-118-01","type":"NDC"}],"standard_charges":[{"gross_charge":115.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-2027-23","type":"NDC"}],"standard_charges":[{"gross_charge":27.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGIC MOUTHWASH ORAL SOLUTION [975049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0489-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4277-16","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0574-4022-35","type":"NDC"}],"standard_charges":[{"gross_charge":233.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR [165559]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"10481-0112-8","type":"NDC"}],"standard_charges":[{"gross_charge":32.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-424-06","type":"NDC"}],"standard_charges":[{"gross_charge":196.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [104159]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-125-22","type":"NDC"}],"standard_charges":[{"gross_charge":166.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-707-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-021-01","type":"NDC"}],"standard_charges":[{"gross_charge":402.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TDAP VACCINE (BOOSTRIX/ADACEL) ADOLESCENT/ADULT WRAPPER [505075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"58160-842-43","type":"NDC"}],"standard_charges":[{"gross_charge":99.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [30070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-402-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMANTADINE HCL 100 MG CAPSULE [364]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-422-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-470-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION [40872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-600-41","type":"NDC"}],"standard_charges":[{"gross_charge":0.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL [194797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-6290-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-436-91","type":"NDC"}],"standard_charges":[{"gross_charge":15.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7135101099","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELLULOSE, OXIDIZED 4\" X 8\" PADS [632122]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-4001-14","type":"NDC"}],"standard_charges":[{"gross_charge":1.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 PACKAGE"}]},{"description":"LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3505-47","type":"NDC"}],"standard_charges":[{"gross_charge":105.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4713-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435179750","type":"NDC"}],"standard_charges":[{"gross_charge":129.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4002-25","type":"NDC"}],"standard_charges":[{"gross_charge":64.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3451-70","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DOFETILIDE 125 MCG CAPSULE [26965]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-490-12","type":"NDC"}],"standard_charges":[{"gross_charge":2.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [2850]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-159-01","type":"NDC"}],"standard_charges":[{"gross_charge":30.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-008-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-250-51","type":"NDC"}],"standard_charges":[{"gross_charge":880.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [120086]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-088-01","type":"NDC"}],"standard_charges":[{"gross_charge":11776.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SEVELAMER CARBONATE 800 MG TABLET [89201]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-720-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [28264]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-978-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-165-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-169-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXCARBAZEPINE 300 MG TABLET [21061]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-722-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":2.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [129976]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"7214003868","type":"NDC"}],"standard_charges":[{"gross_charge":12.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE(PF) 0.2 %-0.9 % SODCHL 545 ML INFIL,HI VAR RATE ELAST PUMP [188549]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4100-64","type":"NDC"}],"standard_charges":[{"gross_charge":875.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0067-01","type":"NDC"}],"standard_charges":[{"gross_charge":3459.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [11082]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0695-04","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3613-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1% (10 MG/ML) W/ EPINEPHRINE 1:100,000 STERILE BUFFERED SOLUTION FOR INJECTION [777014]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"05446-0850-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6027-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6044-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PROPRANOLOL 10 MG TABLET [6656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6550-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [11634]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-685-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERAZOSIN 1 MG CAPSULE [14550]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59746-383-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PAROXETINE 10 MG TABLET [16632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-0097-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEMANTINE 5 MG TABLET [37170]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-173-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY [10603]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61269-736-07","type":"NDC"}],"standard_charges":[{"gross_charge":2.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [176722]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-326-05","type":"NDC"}],"standard_charges":[{"gross_charge":1270.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-22","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-09","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-27","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-966-00","type":"NDC"}],"standard_charges":[{"gross_charge":831.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION [8982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5214-7","type":"NDC"}],"standard_charges":[{"gross_charge":103.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [19596]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0078-0925-25","type":"NDC"}],"standard_charges":[{"gross_charge":205.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0544-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [130647]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1971-21","type":"NDC"}],"standard_charges":[{"gross_charge":3.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0056-15","type":"NDC"}],"standard_charges":[{"gross_charge":133.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOZAPINE 25 MG TABLET [9648]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-0825-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5921-16","type":"NDC"}],"standard_charges":[{"gross_charge":40.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0280-31","type":"NDC"}],"standard_charges":[{"gross_charge":7.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMLODIPINE 2.5 MG TABLET [9070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6369-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PERITONEAL DIALYSIS SOLN 6 (DIANEAL) DEXTR 1.5%-CA 2.5 MEQ/L-MG 0.5 MEQ/L [27796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0941-0424-53","type":"NDC"}],"standard_charges":[{"gross_charge":97.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MANNITOL 20 % INTRAVENOUS SOLUTION [4749]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0990-7715-13","type":"NDC"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [9476]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-128-50","type":"NDC"}],"standard_charges":[{"gross_charge":15.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [173833]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59011-420-20","type":"NDC"}],"standard_charges":[{"gross_charge":23.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-406-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAMIPEXOLE 0.25 MG TABLET [21290]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-197-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE [182441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-009-96","type":"NDC"}],"standard_charges":[{"gross_charge":7.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE (VITAMIN B1) 100 MG TABLET (WRAPPER) [508008]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8068109800","type":"NDC"}],"standard_charges":[{"gross_charge":0.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"XENON XE 133 GAS [40840065]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-4001-04","type":"NDC"}],"standard_charges":[{"gross_charge":371.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121059530","type":"NDC"}],"standard_charges":[{"gross_charge":3.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM ER 120 MG TABLET,EXTENDED RELEASE 24 HR [35177]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0187-2045-30","type":"NDC"}],"standard_charges":[{"gross_charge":10.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3300-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6013-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6136-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0713-0678-15","type":"NDC"}],"standard_charges":[{"gross_charge":16.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEGESTROL 40 MG TABLET [4871]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7236-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-05","type":"NDC"}],"standard_charges":[{"gross_charge":6860.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"QUETIAPINE 100 MG TABLET [21824]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-454-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24208-631-10","type":"NDC"}],"standard_charges":[{"gross_charge":177.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"48433-129-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET [125887]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49884-466-63","type":"NDC"}],"standard_charges":[{"gross_charge":5.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE HCL 0.1 MG TABLET [1755]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-192-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 1 MG TABLET [9638]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-882-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [106804]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55513-730-01","type":"NDC"}],"standard_charges":[{"gross_charge":9221.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-78","type":"NDC"}],"standard_charges":[{"gross_charge":27.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [106364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-462-37","type":"NDC"}],"standard_charges":[{"gross_charge":33.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-494-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE [182441]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-009-06","type":"NDC"}],"standard_charges":[{"gross_charge":7.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETRACAINE HCL (PF) 0.5 % EYE DROPS [131372]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0065-0741-14","type":"NDC"}],"standard_charges":[{"gross_charge":37.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"TICAGRELOR 60 MG TABLET [176801]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0186-0776-60","type":"NDC"}],"standard_charges":[{"gross_charge":20.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-1800-31","type":"NDC"}],"standard_charges":[{"gross_charge":7.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7750-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS IV BOLUS [400296]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":5.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION [10655]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0406-8003-30","type":"NDC"}],"standard_charges":[{"gross_charge":59.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION [125923]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5922-01","type":"NDC"}],"standard_charges":[{"gross_charge":31.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOFETILIDE 125 MCG CAPSULE [26965]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6681-08","type":"NDC"}],"standard_charges":[{"gross_charge":9.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27241-256-11","type":"NDC"}],"standard_charges":[{"gross_charge":28.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [185012]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-711-03","type":"NDC"}],"standard_charges":[{"gross_charge":4036.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 81 MG CHEWABLE TABLET [679]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"48433-129-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUSPIRONE 5 MG TABLET [9324]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-985-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 25 MG TABLET [3774]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-675-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-285-28","type":"NDC"}],"standard_charges":[{"gross_charge":27.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-433-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CARVEDILOL 6.25 MG TABLET [15747]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-154-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 20 MG TABLET [3294]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-116-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 0.4 MG/10 ML (40 MCG/ML) IN 0.9 %SOD.CHLORIDE IV SYRINGE [131065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71506-040-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION [4985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-38","type":"NDC"}],"standard_charges":[{"gross_charge":500.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAT EMULSION 20 % INTRAVENOUS [10014]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0519-09","type":"NDC"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN [36046]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0704-34","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION [119843]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1412-30","type":"NDC"}],"standard_charges":[{"gross_charge":30.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CODEINE SULFATE 30 MG TABLET [1802]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0527-1698-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [6580]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0713-0351-02","type":"NDC"}],"standard_charges":[{"gross_charge":12.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH [117356]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-7313-31","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG CAPSULE [98]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1987-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-500-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"CLOBETASOL 0.05 % TOPICAL CREAM [9630]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"42291-076-15","type":"NDC"}],"standard_charges":[{"gross_charge":5.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIOTHYRONINE 5 MCG TABLET [10443]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42794-018-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOCONAZOLE 200 MG TABLET [10369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-4026-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [29302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60432-212-08","type":"NDC"}],"standard_charges":[{"gross_charge":167.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-0829-1","type":"NDC"}],"standard_charges":[{"gross_charge":22.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-814-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-280-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUCCINYLCHOLINE CHORIDE 20 MG/ML INTRAVENOUS WRAPPER [339545]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-783-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 2 MG/ML INJECTION SYRINGE [5170]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76045-004-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BISACODYL 10 MG RECTAL SUPPOSITORY [1080]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8142102101","type":"NDC"}],"standard_charges":[{"gross_charge":2.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-0293-05","type":"NDC"}],"standard_charges":[{"gross_charge":25.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1761-30","type":"NDC"}],"standard_charges":[{"gross_charge":5.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9431-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9506-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION (PEDS) [978730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7750-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11074]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0709-48","type":"NDC"}],"standard_charges":[{"gross_charge":8.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK [128040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9147-30","type":"NDC"}],"standard_charges":[{"gross_charge":10.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0123-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-17","type":"NDC"}],"standard_charges":[{"gross_charge":2.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-0201-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1852-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-033-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TENECTEPLASE 50 MG INJECTION FOR ACUTE ISCHEMIC STROKE [632538]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-037-06","type":"NDC"}],"standard_charges":[{"gross_charge":22243.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-085-25","type":"NDC"}],"standard_charges":[{"gross_charge":25477.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"QUETIAPINE 25 MG TABLET [21823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-630-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION [16169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-418-20","type":"NDC"}],"standard_charges":[{"gross_charge":749.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-327-02","type":"NDC"}],"standard_charges":[{"gross_charge":190.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67850-021-00","type":"NDC"}],"standard_charges":[{"gross_charge":8.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69618-059-51","type":"NDC"}],"standard_charges":[{"gross_charge":10.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0068-0597-01","type":"NDC"}],"standard_charges":[{"gross_charge":247.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [176025]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0078-0777-20","type":"NDC"}],"standard_charges":[{"gross_charge":32.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION (PEDS) [978729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2050-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 1 MG/ML INJECTION SOLUTION WRAPPER [339459]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2305-16","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9094-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MEDROXYPROGESTERONE 2.5 MG TABLET [4855]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0872-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0574-7226-12","type":"NDC"}],"standard_charges":[{"gross_charge":19.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3290-91","type":"NDC"}],"standard_charges":[{"gross_charge":12.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG DISINTEGRATING TABLET [39713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"41163-449-08","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-301-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-044-13","type":"NDC"}],"standard_charges":[{"gross_charge":12738.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL 4 MG TABLET [10778]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-621-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 300 MG TABLET [311]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-688-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL IV INJECTION [410075]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL [194797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-6290-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PHENYLEPHRINE 0.4 MG/10 ML (40 MCG/ML) IN 0.9 %SOD.CHLORIDE IV SYRINGE [131065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9031-1","type":"NDC"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-161-20","type":"NDC"}],"standard_charges":[{"gross_charge":44.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 4 % TOPICAL PATCH [121301]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71399-4456-1","type":"NDC"}],"standard_charges":[{"gross_charge":2.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOTHYROXINE 112 MCG TABLET [10404]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0074-9296-90","type":"NDC"}],"standard_charges":[{"gross_charge":4.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9162-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION [3769]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-4201-01","type":"NDC"}],"standard_charges":[{"gross_charge":49.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EMPAGLIFLOZIN 10 MG TABLET [170957]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0597-0152-37","type":"NDC"}],"standard_charges":[{"gross_charge":45.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3451-70","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DESMOPRESSIN 0.1 MG TABLET [16052]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-220-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-174-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM IV SYRINGE 15 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [508158]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-248-47","type":"NDC"}],"standard_charges":[{"gross_charge":56.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-252-20","type":"NDC"}],"standard_charges":[{"gross_charge":2.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"VALACYCLOVIR 500 MG TABLET [13133]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-042-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59651-008-15","type":"NDC"}],"standard_charges":[{"gross_charge":36.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-26","type":"NDC"}],"standard_charges":[{"gross_charge":11.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-97","type":"NDC"}],"standard_charges":[{"gross_charge":16.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-05","type":"NDC"}],"standard_charges":[{"gross_charge":5.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-665-01","type":"NDC"}],"standard_charges":[{"gross_charge":54.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67850-041-00","type":"NDC"}],"standard_charges":[{"gross_charge":12.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TROPICAMIDE 1 % EYE DROPS [8250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-121-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/10ML INJECTION SYRINGE [2848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3316-1","type":"NDC"}],"standard_charges":[{"gross_charge":24.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION [130943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0013-05","type":"NDC"}],"standard_charges":[{"gross_charge":120.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTASE 9,000 UNIT CHEWABLE TABLET [122812]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0045093060","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [132049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-4675-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0132-0081-12","type":"NDC"}],"standard_charges":[{"gross_charge":2.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9746-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6044-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7218-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-101-67","type":"NDC"}],"standard_charges":[{"gross_charge":2.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"47335-993-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-88","type":"NDC"}],"standard_charges":[{"gross_charge":88.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LOSARTAN 25 MG TABLET [14823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-504-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NAPROXEN 250 MG TABLET [5391]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-594-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-405-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"OR-HEPARINZED SALINE (WIN) 10,000 UNITS/1000 ML SOLUTION [632333]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-540-05","type":"NDC"}],"standard_charges":[{"gross_charge":9.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-660-05","type":"NDC"}],"standard_charges":[{"gross_charge":5.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-553-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAZOLAMIDE 250 MG TABLET [113]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70756-721-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71288-162-30","type":"NDC"}],"standard_charges":[{"gross_charge":66.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-1145-01","type":"NDC"}],"standard_charges":[{"gross_charge":1938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3270-99","type":"NDC"}],"standard_charges":[{"gross_charge":37.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WHITE PETROLATUM TOPICAL OINTMENT IN PACKET [132649]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0053-45","type":"NDC"}],"standard_charges":[{"gross_charge":5.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1.5 GRAM/300 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [206396]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0124-04","type":"NDC"}],"standard_charges":[{"gross_charge":95.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6142-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 0.2 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN [130864]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-0018-01","type":"NDC"}],"standard_charges":[{"gross_charge":286.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG DISINTEGRATING TABLET [39713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5754-24","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [130190]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7265-41","type":"NDC"}],"standard_charges":[{"gross_charge":9.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (GAMMAGARD LIQUID) 10 %-GLY-IGA OVER 50 MCG/ML INJ SOLN [175230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-2700-12","type":"NDC"}],"standard_charges":[{"gross_charge":4124.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-284-25","type":"NDC"}],"standard_charges":[{"gross_charge":3.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60432-150-04","type":"NDC"}],"standard_charges":[{"gross_charge":30.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-7063-0","type":"NDC"}],"standard_charges":[{"gross_charge":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREGABALIN 25 MG CAPSULE [42162]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-473-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-524-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-853-50","type":"NDC"}],"standard_charges":[{"gross_charge":110.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VENLAFAXINE 37.5 MG TABLET [12207]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-844-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-NITROPRUSSIDE INFUSION 100 MG/250 ML (0.4 MG/ML) IN NS [440062]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-202-02","type":"NDC"}],"standard_charges":[{"gross_charge":2338.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-411-82","type":"NDC"}],"standard_charges":[{"gross_charge":23.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4001-22","type":"NDC"}],"standard_charges":[{"gross_charge":5.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [187243]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1309-01","type":"NDC"}],"standard_charges":[{"gross_charge":1088.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9541-24","type":"NDC"}],"standard_charges":[{"gross_charge":3.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3113-90","type":"NDC"}],"standard_charges":[{"gross_charge":14.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5854-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10702-018-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-55","type":"NDC"}],"standard_charges":[{"gross_charge":32.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-602-03","type":"NDC"}],"standard_charges":[{"gross_charge":18.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [185012]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-747-03","type":"NDC"}],"standard_charges":[{"gross_charge":13.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42571-147-26","type":"NDC"}],"standard_charges":[{"gross_charge":25.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE [40840057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45548-141-10","type":"NDC"}],"standard_charges":[{"gross_charge":97.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"47335-993-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-252-51","type":"NDC"}],"standard_charges":[{"gross_charge":1010.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET [186297]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"61958-2501-3","type":"NDC"}],"standard_charges":[{"gross_charge":393.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-94","type":"NDC"}],"standard_charges":[{"gross_charge":1.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BENZONATATE 100 MG CAPSULE [988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-214-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLESTYRAMINE 4 GRAM ORAL POWDER FOR SUSPENSION IN A PACKET [211218]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-529-60","type":"NDC"}],"standard_charges":[{"gross_charge":4.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5216-2","type":"NDC"}],"standard_charges":[{"gross_charge":191.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 1.25 MG/ML INJECTION [632141]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-424-01","type":"NDC"}],"standard_charges":[{"gross_charge":376.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [30807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-5050-1","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9386-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SURGICAL LUBRICANT JELLY TOPICAL [123549]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0281020545","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION [37642]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0129-01","type":"NDC"}],"standard_charges":[{"gross_charge":53.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6142-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6151-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3289-91","type":"NDC"}],"standard_charges":[{"gross_charge":10.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5854-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"11701-038-16","type":"NDC"}],"standard_charges":[{"gross_charge":19.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICONAZOLE NITRATE 2 % TOPICAL OINTMENT [13651]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"11701-067-23","type":"NDC"}],"standard_charges":[{"gross_charge":20.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-443-15","type":"NDC"}],"standard_charges":[{"gross_charge":1.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 20 MG CAPSULE [10070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50111-648-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FINASTERIDE 5 MG TABLET [10037]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-314-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [30070]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-467-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [191625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59572-775-01","type":"NDC"}],"standard_charges":[{"gross_charge":36292.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [176723]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-318-05","type":"NDC"}],"standard_charges":[{"gross_charge":413.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-29","type":"NDC"}],"standard_charges":[{"gross_charge":5.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION [191429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-103-10","type":"NDC"}],"standard_charges":[{"gross_charge":1444.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFPODOXIME 200 MG TABLET [9469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-879-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THYROID (PORK) 30 MG TABLET [130472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75834-311-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0072-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [10726]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1051-02","type":"NDC"}],"standard_charges":[{"gross_charge":61.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1708-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION [119843]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1412-50","type":"NDC"}],"standard_charges":[{"gross_charge":11.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-17","type":"NDC"}],"standard_charges":[{"gross_charge":10.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"CEFADROXIL 500 MG CAPSULE [9436]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-388-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-040-01","type":"NDC"}],"standard_charges":[{"gross_charge":7.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM 600 MG (AS CARBONATE)-VITAMIN D3 10 MCG (400 UNIT) TABLET [76978]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055501700","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-732-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57894-160-01","type":"NDC"}],"standard_charges":[{"gross_charge":1316.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-163-00","type":"NDC"}],"standard_charges":[{"gross_charge":182.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-423-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TORSEMIDE 20 MG TABLET [18293]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-539-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 6.25 MG TABLET [15747]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-854-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-5103-1","type":"NDC"}],"standard_charges":[{"gross_charge":63.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-432-80","type":"NDC"}],"standard_charges":[{"gross_charge":5.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-5781-1","type":"NDC"}],"standard_charges":[{"gross_charge":9.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARVEDILOL 25 MG TABLET [15748]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0007-4142-20","type":"NDC"}],"standard_charges":[{"gross_charge":18.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [104962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0116-4005-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [165023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1660-10","type":"NDC"}],"standard_charges":[{"gross_charge":132.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2720-31","type":"NDC"}],"standard_charges":[{"gross_charge":9.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3356-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-0201-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DEXTROSE 40 % ORAL GEL [27466]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0574006930","type":"NDC"}],"standard_charges":[{"gross_charge":8.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6244-01","type":"NDC"}],"standard_charges":[{"gross_charge":46.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10019-553-90","type":"NDC"}],"standard_charges":[{"gross_charge":52.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV [110258]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43066-360-20","type":"NDC"}],"standard_charges":[{"gross_charge":67.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-120-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-169-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MODAFINIL 100 MG TABLET [24702]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-154-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE HCL 0.1 MG TABLET [1755]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-113-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 200 MG CAPSULE [24501]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-142-71","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-940-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70700-188-22","type":"NDC"}],"standard_charges":[{"gross_charge":82.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAALOX/DIPHENHYDRAMINE 5 ML ORAL SOLUTION [606156]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4003-26","type":"NDC"}],"standard_charges":[{"gross_charge":3.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FERROUS SULFATE ORAL DROPS 15 MG IRON (75 MG)/ML [632150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0087074002","type":"NDC"}],"standard_charges":[{"gross_charge":156.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-4136-73","type":"NDC"}],"standard_charges":[{"gross_charge":47.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9155-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-38","type":"NDC"}],"standard_charges":[{"gross_charge":4.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WATER FOR INJECTION, STERILE INJECTION SOLUTION [11671]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4887-17","type":"NDC"}],"standard_charges":[{"gross_charge":2.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6102-10","type":"NDC"}],"standard_charges":[{"gross_charge":14.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE WITH MEDIUM MASK [187722]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0456-0745-13","type":"NDC"}],"standard_charges":[{"gross_charge":139.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DICLOXACILLIN 500 MG CAPSULE [2415]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-2258-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10135-620-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-308-01","type":"NDC"}],"standard_charges":[{"gross_charge":55.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COLCHICINE 0.6 MG TABLET [1821]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-899-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZONISAMIDE 100 MG CAPSULE [27780]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-230-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 100 MG CAPSULE [24500]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-436-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [169631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63824-008-15","type":"NDC"}],"standard_charges":[{"gross_charge":1.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAVASTATIN 20 MG TABLET [11111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-789-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70700-189-22","type":"NDC"}],"standard_charges":[{"gross_charge":164.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYLEPHRINE 2.5 % EYE DROPS [6246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70756-629-25","type":"NDC"}],"standard_charges":[{"gross_charge":85.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [7309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3352-1","type":"NDC"}],"standard_charges":[{"gross_charge":46.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0115-1365-29","type":"NDC"}],"standard_charges":[{"gross_charge":5.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9875-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-48","type":"NDC"}],"standard_charges":[{"gross_charge":4.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9543-03","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9558-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CITALOPRAM 10 MG TABLET [30264]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6084-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10019-553-90","type":"NDC"}],"standard_charges":[{"gross_charge":52.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-501-64","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-240-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"48102-057-11","type":"NDC"}],"standard_charges":[{"gross_charge":25.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [120087]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-087-01","type":"NDC"}],"standard_charges":[{"gross_charge":18739.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CILOSTAZOL 50 MG TABLET [24473]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-176-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NAPROXEN 250 MG TABLET [5391]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-594-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"NORTRIPTYLINE 25 MG CAPSULE [5675]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51672-4002-5","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-209-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEPHALEXIN 250 MG CAPSULE [9499]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-152-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PROPARACAINE 0.5 % EYE DROPS [6644]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-016-01","type":"NDC"}],"standard_charges":[{"gross_charge":81.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68308-505-47","type":"NDC"}],"standard_charges":[{"gross_charge":0.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION [8982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76125-790-25","type":"NDC"}],"standard_charges":[{"gross_charge":109.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3475-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1154-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [25365]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3503-41","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7924-09","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM CITRATE ORAL SOLUTION [4712]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-6787-44","type":"NDC"}],"standard_charges":[{"gross_charge":5.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-937-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE IVPB 5 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-131-82","type":"NDC"}],"standard_charges":[{"gross_charge":5.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-009-24","type":"NDC"}],"standard_charges":[{"gross_charge":9.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION [10442]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"39822-0151-1","type":"NDC"}],"standard_charges":[{"gross_charge":970.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-106-11","type":"NDC"}],"standard_charges":[{"gross_charge":38.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALSARTAN 80 MG TABLET [31209]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-623-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-421-16","type":"NDC"}],"standard_charges":[{"gross_charge":18.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-474-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-664-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PHENAZOPYRIDINE 100 MG TABLET [6193]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-681-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PHENYLEPHRINE 0.4 MG/10 ML (40 MCG/ML) IN 0.9 %SOD.CHLORIDE IV SYRINGE [131065]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-9032-1","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0071-3740-66","type":"NDC"}],"standard_charges":[{"gross_charge":4.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [190842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0126-12","type":"NDC"}],"standard_charges":[{"gross_charge":55.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION (DRY VIAL) [978604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-9566-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0713-0536-06","type":"NDC"}],"standard_charges":[{"gross_charge":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3288-91","type":"NDC"}],"standard_charges":[{"gross_charge":3.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"QUETIAPINE 25 MG TABLET [21823]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-452-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 30 MG CAPSULE [88704]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-630-31","type":"NDC"}],"standard_charges":[{"gross_charge":2.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE HCL 2 MG/250 ML (8 MCG/ML) IN 0.9 % SODIUM CHLOR IV SOLN [132566]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-168-01","type":"NDC"}],"standard_charges":[{"gross_charge":58854.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORNASE ALFA 5 MG/30 ML STERILE WATER INTRAPLEURAL [400814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-100-40","type":"NDC"}],"standard_charges":[{"gross_charge":292.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMITRIPTYLINE 10 MG TABLET [432]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-131-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55566-2200-0","type":"NDC"}],"standard_charges":[{"gross_charge":139.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"58980-409-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-767-99","type":"NDC"}],"standard_charges":[{"gross_charge":16.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-17","type":"NDC"}],"standard_charges":[{"gross_charge":10.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-591-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 30 MG TABLET [2475]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68682-006-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3302-1","type":"NDC"}],"standard_charges":[{"gross_charge":43.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TECHNETIUM TC 99M PYROPHOSPHATE [40840067]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9003-77","type":"NDC"}],"standard_charges":[{"gross_charge":416.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION [172891]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0003-3734-13","type":"NDC"}],"standard_charges":[{"gross_charge":22454.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LORAZEPAM 2 MG/ML ORAL CONCENTRATE [4571]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3532-44","type":"NDC"}],"standard_charges":[{"gross_charge":78.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQUID [194404]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"1513702127","type":"NDC"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"},{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL [29676]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"45802-357-58","type":"NDC"}],"standard_charges":[{"gross_charge":6.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-041-64","type":"NDC"}],"standard_charges":[{"gross_charge":514.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-779-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [193630]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-272-01","type":"NDC"}],"standard_charges":[{"gross_charge":1385.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION (WIN) [632162]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6157-0","type":"NDC"}],"standard_charges":[{"gross_charge":5.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 300 MG CAPSULE [18308]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-591-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 4 % EYE DROPS [6282]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-206-15","type":"NDC"}],"standard_charges":[{"gross_charge":195.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION [41463]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-186-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SUMATRIPTAN 50 MG TABLET [15328]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-147-36","type":"NDC"}],"standard_charges":[{"gross_charge":1.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-REMIFENTANIL-0.9% SODIUM CHLORIDE IV [440045]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-198-00","type":"NDC"}],"standard_charges":[{"gross_charge":111.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"APREPITANT 40 MG CAPSULE [76843]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-583-40","type":"NDC"}],"standard_charges":[{"gross_charge":77.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-639-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"NIFEDIPINE 10 MG CAPSULE [5558]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-211-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-73","type":"NDC"}],"standard_charges":[{"gross_charge":20.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [181531]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0069-0809-01","type":"NDC"}],"standard_charges":[{"gross_charge":1375.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"MINERAL OIL ENEMA [5087]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132-0301-40","type":"NDC"}],"standard_charges":[{"gross_charge":6.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9318-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE (KETALAR) 1000 MG/100 ML (10 MG/ML) IN 0.9% SODIUM CHLORIDE (NS) [339163]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9509-01","type":"NDC"}],"standard_charges":[{"gross_charge":11.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION [130088]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9104-20","type":"NDC"}],"standard_charges":[{"gross_charge":12.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POVIDONE-IODINE 10 % TOPICAL SWAB [27886]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10819-3885-2","type":"NDC"}],"standard_charges":[{"gross_charge":0.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-283-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 1 MG/ML INJECTION SYRINGE [5374]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-750-11","type":"NDC"}],"standard_charges":[{"gross_charge":40.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IVIG (PRIVIGEN) 10%-PRO-IGA 0 TO 50 MCG/ML IV SYR (NEONATAL) [979169]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44206-436-05","type":"NDC"}],"standard_charges":[{"gross_charge":1045.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-101-10","type":"NDC"}],"standard_charges":[{"gross_charge":8.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50242-041-63","type":"NDC"}],"standard_charges":[{"gross_charge":389.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIRTAZAPINE 15 MG TABLET [17466]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-086-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129578]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-106-15","type":"NDC"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-00","type":"NDC"}],"standard_charges":[{"gross_charge":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-325-10","type":"NDC"}],"standard_charges":[{"gross_charge":28.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CINACALCET 30 MG TABLET [38100]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-410-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/10ML INJECTION SYRINGE [2848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3316-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4007-39","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [130944]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0011-03","type":"NDC"}],"standard_charges":[{"gross_charge":64.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR KIT (WRAPPER) [508006]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0078-0825-81","type":"NDC"}],"standard_charges":[{"gross_charge":18675.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0914-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-1870-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS [400297]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7751-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IV BOLUS [400293]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 1 MG/ML INJECTION SYRINGE [124908]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1283-17","type":"NDC"}],"standard_charges":[{"gross_charge":8.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [167937]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2308-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-33","type":"NDC"}],"standard_charges":[{"gross_charge":12.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435179850","type":"NDC"}],"standard_charges":[{"gross_charge":60.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6007-01","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [165400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-189-01","type":"NDC"}],"standard_charges":[{"gross_charge":98.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE 4 MG TABLET [2327]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-718-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-723-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION [129393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60793-215-05","type":"NDC"}],"standard_charges":[{"gross_charge":131.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [127343]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-202-08","type":"NDC"}],"standard_charges":[{"gross_charge":84.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69315-910-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3426-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MINERAL OIL ENEMA [5087]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132030140","type":"NDC"}],"standard_charges":[{"gross_charge":4.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9251-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [195370]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0173-0898-03","type":"NDC"}],"standard_charges":[{"gross_charge":35383.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 15 MG/ML INJECTION SOLUTION [22472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0069-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION [107671]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0456-0600-01","type":"NDC"}],"standard_charges":[{"gross_charge":543.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION [4985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0301-10","type":"NDC"}],"standard_charges":[{"gross_charge":23.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0597-0075-75","type":"NDC"}],"standard_charges":[{"gross_charge":142.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-05","type":"NDC"}],"standard_charges":[{"gross_charge":6830.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-106-67","type":"NDC"}],"standard_charges":[{"gross_charge":4.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"39822-0190-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MODIFIED LANOLIN 100 % TOPICAL CREAM [190483]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"4467710020","type":"NDC"}],"standard_charges":[{"gross_charge":22.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERAZOSIN 1 MG CAPSULE [14550]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-764-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51991-144-99","type":"NDC"}],"standard_charges":[{"gross_charge":46.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WHITE PETROLATUM TOPICAL OINTMENT IN PACKET [132649]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"57896-114-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXCARBAZEPINE 150 MG TABLET [27049]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-711-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONAZEPAM 0.125 MG DISINTEGRATING TABLET [35625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-364-06","type":"NDC"}],"standard_charges":[{"gross_charge":2.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [119135]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-414-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"73293-0001-1","type":"NDC"}],"standard_charges":[{"gross_charge":4.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [128760]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0132-0202-20","type":"NDC"}],"standard_charges":[{"gross_charge":4.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-0445-35","type":"NDC"}],"standard_charges":[{"gross_charge":0.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [25365]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3503-41","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"WARFARIN 2.5 MG TABLET [8750]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0832-1213-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [9466]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16714-403-01","type":"NDC"}],"standard_charges":[{"gross_charge":206.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 1 MG/ML INJECTION SOLUTION WRAPPER [339091]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"16729-526-63","type":"NDC"}],"standard_charges":[{"gross_charge":17.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MELATONIN 3 MG TABLET [16830]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055503601","type":"NDC"}],"standard_charges":[{"gross_charge":0.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-931-11","type":"NDC"}],"standard_charges":[{"gross_charge":56.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-311-10","type":"NDC"}],"standard_charges":[{"gross_charge":12.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-10","type":"NDC"}],"standard_charges":[{"gross_charge":108.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"QUETIAPINE 100 MG TABLET [21824]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-349-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETALOL 100 MG TABLET [10373]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-439-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-633-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CELECOXIB 100 MG CAPSULE [24500]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-141-31","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"71839-104-01","type":"NDC"}],"standard_charges":[{"gross_charge":46.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"COVID VAC 2023-24 (12 YR UP)(ANDUSOMERAN)(PF) 50 MCG/0.5 ML IM SYRINGE [204400]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"80777-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":203.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0008-4001-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-3919-50","type":"NDC"}],"standard_charges":[{"gross_charge":1086.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [180351]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0023-5853-18","type":"NDC"}],"standard_charges":[{"gross_charge":10.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0054-3294-46","type":"NDC"}],"standard_charges":[{"gross_charge":15.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARGATROBAN 50 MG/50 ML (1 MG/ML) WRAPPER [508177]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9559-01","type":"NDC"}],"standard_charges":[{"gross_charge":284.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0077-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE IV SYRINGE 40 MG/ML IN WATER (PEDIATRIC) (PREMIX) [977066]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1708-40","type":"NDC"}],"standard_charges":[{"gross_charge":7.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINACLOTIDE 290 MCG CAPSULE [117353]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0456-1202-30","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0536-1268-12","type":"NDC"}],"standard_charges":[{"gross_charge":12.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-473-32","type":"NDC"}],"standard_charges":[{"gross_charge":3.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE [38224]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-215-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-799-40","type":"NDC"}],"standard_charges":[{"gross_charge":22.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62935-227-10","type":"NDC"}],"standard_charges":[{"gross_charge":1110.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64380-737-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-076-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GUANFACINE 1 MG TABLET [10149]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68094-065-59","type":"NDC"}],"standard_charges":[{"gross_charge":9.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOCYANINE GREEN 1.25 MG/ML INJECTION [632141]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-725-01","type":"NDC"}],"standard_charges":[{"gross_charge":792.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL [194797]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71266-6290-1","type":"NDC"}],"standard_charges":[{"gross_charge":33.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION [8982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76125-790-26","type":"NDC"}],"standard_charges":[{"gross_charge":105.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9577-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE IVPB 5 MG/ML IN NACL (ISO-OSM) (PEDIATRIC) (PREMIX) [450267]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1055-48","type":"NDC"}],"standard_charges":[{"gross_charge":6.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GLYCERIN 99.5 % TOPICAL SOLUTION [82033]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0395-1031-16","type":"NDC"}],"standard_charges":[{"gross_charge":65.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [10734]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3755-75","type":"NDC"}],"standard_charges":[{"gross_charge":35.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIODARONE 200 MG TABLET [9066]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6993-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-542-02","type":"NDC"}],"standard_charges":[{"gross_charge":17.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-132-82","type":"NDC"}],"standard_charges":[{"gross_charge":12.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-322-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-730-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [168166]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-523-11","type":"NDC"}],"standard_charges":[{"gross_charge":51.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVETIRACETAM 500 MG TABLET [26817]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-657-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-22","type":"NDC"}],"standard_charges":[{"gross_charge":6.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-482-03","type":"NDC"}],"standard_charges":[{"gross_charge":11.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-495-27","type":"NDC"}],"standard_charges":[{"gross_charge":8.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64253-900-30","type":"NDC"}],"standard_charges":[{"gross_charge":22.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [131804]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65174-270-30","type":"NDC"}],"standard_charges":[{"gross_charge":24875.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-231-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"IVIG (OCTAGAM) 5%-MALT-IGA OVER 50 MCG/ML IV SOLN [175925]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68982-840-04","type":"NDC"}],"standard_charges":[{"gross_charge":2127.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69344-102-33","type":"NDC"}],"standard_charges":[{"gross_charge":806.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0046-0749-05","type":"NDC"}],"standard_charges":[{"gross_charge":1044.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALOXONE 4 MG/ACTUATION NASAL SPRAY [177837]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-2165-19","type":"NDC"}],"standard_charges":[{"gross_charge":99.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9660-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-48","type":"NDC"}],"standard_charges":[{"gross_charge":5.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-9112-76","type":"NDC"}],"standard_charges":[{"gross_charge":19.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 4 % TOPICAL CREAM [23461]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0496-0882-05","type":"NDC"}],"standard_charges":[{"gross_charge":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [212730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"19515-904-52","type":"NDC"}],"standard_charges":[{"gross_charge":59.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-676-11","type":"NDC"}],"standard_charges":[{"gross_charge":31.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"47335-330-40","type":"NDC"}],"standard_charges":[{"gross_charge":67.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET [2012]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026885411","type":"NDC"}],"standard_charges":[{"gross_charge":0.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [104962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-779-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION [191669]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-223-01","type":"NDC"}],"standard_charges":[{"gross_charge":3756.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METFORMIN 850 MG TABLET [14719]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-143-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-145-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BRIMONIDINE 0.2 % EYE DROPS [17881]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61314-143-15","type":"NDC"}],"standard_charges":[{"gross_charge":41.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-940-10","type":"NDC"}],"standard_charges":[{"gross_charge":19.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-494-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PRAZOSIN 2 MG CAPSULE [6469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70954-020-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9250-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9595-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0168-0357-05","type":"NDC"}],"standard_charges":[{"gross_charge":20.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [130348]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904549261","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [129971]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-673-77","type":"NDC"}],"standard_charges":[{"gross_charge":14.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROSUVASTATIN 10 MG TABLET [35134]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-883-90","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MISOPROSTOL 100 MCG TABLET [10628]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43386-160-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"THIAMINE (VITAMIN B1) 100 MG TABLET (WRAPPER) [508008]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"5026885111","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARBAMAZEPINE 200 MG TABLET [1357]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-385-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-208-30","type":"NDC"}],"standard_charges":[{"gross_charge":18.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [173831]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59011-410-20","type":"NDC"}],"standard_charges":[{"gross_charge":12.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION [98312]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59338-775-01","type":"NDC"}],"standard_charges":[{"gross_charge":3306.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59762-3110-1","type":"NDC"}],"standard_charges":[{"gross_charge":55.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-341-44","type":"NDC"}],"standard_charges":[{"gross_charge":16.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN B COMPLEX AND VITAMIN C NO.20-FOLIC ACID 1 MG CAPSULE [38978]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"6304462201","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-PHENYLEPHRINE INFUSION 10 MG/250 ML (40 MCG/ML) IN NS (BEV) [444689]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-751-00","type":"NDC"}],"standard_charges":[{"gross_charge":862.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRIMIDONE 250 MG TABLET [6544]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-203-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-021-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFTAZIDIME 1,000 MG/25 ML (40 MG/ML) IN NS STOCK DILUTION (PEDIATRIC) [508191]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4005-40","type":"NDC"}],"standard_charges":[{"gross_charge":22.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [130004]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-3034-20","type":"NDC"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [29302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0759-08","type":"NDC"}],"standard_charges":[{"gross_charge":108.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-20","type":"NDC"}],"standard_charges":[{"gross_charge":8.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10106]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0503-48","type":"NDC"}],"standard_charges":[{"gross_charge":6.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0409-7332-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-9501-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0121-21","type":"NDC"}],"standard_charges":[{"gross_charge":1.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DIPHENHYDRAMINE 25 MG CAPSULE [2509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5306-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CITALOPRAM 20 MG TABLET [21062]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"13668-010-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACOSAMIDE 100 MG TABLET [96969]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"33342-303-09","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROXYUREA 500 MG CAPSULE [10236]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49884-724-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAMOTIDINE 20 MG TABLET [10011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-595-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-010-02","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [22473]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 5 % TOPICAL OINTMENT [41831]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68462-418-20","type":"NDC"}],"standard_charges":[{"gross_charge":20.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AZATHIOPRINE 25 MG SPLIT TAB [975011]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69238-1076-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1573-1","type":"NDC"}],"standard_charges":[{"gross_charge":14.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0188-13","type":"NDC"}],"standard_charges":[{"gross_charge":2.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLCELLULOSE (WITH SUGAR) ORAL POWDER [19739]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0135-0089-69","type":"NDC"}],"standard_charges":[{"gross_charge":23.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7612-00","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-53","type":"NDC"}],"standard_charges":[{"gross_charge":12.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [7309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6637-34","type":"NDC"}],"standard_charges":[{"gross_charge":25.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17478-404-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [185012]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-741-03","type":"NDC"}],"standard_charges":[{"gross_charge":13.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 2 MG TABLET [70306]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-087-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIAZEPAM 5 MG TABLET [2405]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-285-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"DOXEPIN 10 MG CAPSULE [2608]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-436-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFADROXIL 250 MG/5 ML ORAL SUSPENSION [9438]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57237-097-01","type":"NDC"}],"standard_charges":[{"gross_charge":47.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"57237-274-24","type":"NDC"}],"standard_charges":[{"gross_charge":150.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VITAMIN A AND D TOPICAL OINTMENT [15283]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"57896-112-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62559-157-17","type":"NDC"}],"standard_charges":[{"gross_charge":2.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION FOR NEBULIZATION [430038]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-694-04","type":"NDC"}],"standard_charges":[{"gross_charge":14.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE [38062]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-907-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-437-91","type":"NDC"}],"standard_charges":[{"gross_charge":19.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE [130805]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"7430000070","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8373079830","type":"NDC"}],"standard_charges":[{"gross_charge":47.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9622-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0270-1316-35","type":"NDC"}],"standard_charges":[{"gross_charge":200.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1159-18","type":"NDC"}],"standard_charges":[{"gross_charge":5.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-18","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10019-553-90","type":"NDC"}],"standard_charges":[{"gross_charge":52.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-121-66","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50383-233-10","type":"NDC"}],"standard_charges":[{"gross_charge":150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55150-114-20","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHENAMINE HIPPURATE 1 GRAM TABLET [10549]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-694-11","type":"NDC"}],"standard_charges":[{"gross_charge":4.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"633232-367-41","type":"NDC"}],"standard_charges":[{"gross_charge":307.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 VIAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-492-57","type":"NDC"}],"standard_charges":[{"gross_charge":10.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-660-05","type":"NDC"}],"standard_charges":[{"gross_charge":4.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GABAPENTIN 100 MG CAPSULE [18309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-101-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-368-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NALTREXONE 50 MG TABLET [10685]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68094-853-62","type":"NDC"}],"standard_charges":[{"gross_charge":5.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69344-102-33","type":"NDC"}],"standard_charges":[{"gross_charge":600.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70860-301-41","type":"NDC"}],"standard_charges":[{"gross_charge":9.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-432-91","type":"NDC"}],"standard_charges":[{"gross_charge":5.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-8014-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-4114-50","type":"NDC"}],"standard_charges":[{"gross_charge":15.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"45802-732-00","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION [191769]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51144-030-01","type":"NDC"}],"standard_charges":[{"gross_charge":12423.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"52380-1905-4","type":"NDC"}],"standard_charges":[{"gross_charge":68.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PEDI MULTIVIT NO.77-VIT D3 750 UNIT-VIT K 500 MCG/0.5 ML ORAL DROPS [170064]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5820400404","type":"NDC"}],"standard_charges":[{"gross_charge":124.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60505-6130-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-35","type":"NDC"}],"standard_charges":[{"gross_charge":27.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION [37989]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66733-948-23","type":"NDC"}],"standard_charges":[{"gross_charge":2291.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-855-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PRIMIDONE 50 MG TABLET [11129]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-202-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-354-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-697-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-015-62","type":"NDC"}],"standard_charges":[{"gross_charge":2.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [121407]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-380-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"69374-946-04","type":"NDC"}],"standard_charges":[{"gross_charge":19.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"72485-670-31","type":"NDC"}],"standard_charges":[{"gross_charge":24.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER [105699]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"78206-126-01","type":"NDC"}],"standard_charges":[{"gross_charge":276.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP [70693]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-7511-01","type":"NDC"}],"standard_charges":[{"gross_charge":14.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0075-2915-01","type":"NDC"}],"standard_charges":[{"gross_charge":103.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-6815-45","type":"NDC"}],"standard_charges":[{"gross_charge":18.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9162-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE [12185]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5315-89","type":"NDC"}],"standard_charges":[{"gross_charge":0.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MICAFUNGIN 100 MG INTRAVENOUS SOLUTION [77685]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0469-3211-10","type":"NDC"}],"standard_charges":[{"gross_charge":518.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0960-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-1020-01","type":"NDC"}],"standard_charges":[{"gross_charge":138.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 325 MG TABLET [7311]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1046-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ISONIAZID 100 MG TABLET [4026]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0066-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CALCIUM POLYCARBOPHIL 625 MG TABLET [11046]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-2500-91","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"24208-910-19","type":"NDC"}],"standard_charges":[{"gross_charge":24.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PRAVASTATIN 20 MG TABLET [11111]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-178-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-20","type":"NDC"}],"standard_charges":[{"gross_charge":44.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68001-531-46","type":"NDC"}],"standard_charges":[{"gross_charge":6.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORZOLAMIDE 2 % EYE DROPS [14471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70069-501-01","type":"NDC"}],"standard_charges":[{"gross_charge":23.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70095-050-01","type":"NDC"}],"standard_charges":[{"gross_charge":14.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OFLOXACIN 0.3 % EYE DROPS [19746]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70756-607-30","type":"NDC"}],"standard_charges":[{"gross_charge":32.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 15 MG IMMEDIATE RELEASE TABLET [5178]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0235-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [24844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-1161-37","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 250 MG TABLET [5015]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1453-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [8880]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904533260","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"14362-0111-3","type":"NDC"}],"standard_charges":[{"gross_charge":53.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFEPIME 2 GRAM SOLUTION FOR INJECTION [16371]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-131-10","type":"NDC"}],"standard_charges":[{"gross_charge":13.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NAPROXEN 250 MG TABLET [5391]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-594-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-639-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55513-222-01","type":"NDC"}],"standard_charges":[{"gross_charge":15025.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GABAPENTIN 100 MG CAPSULE [18309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-580-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACOSAMIDE 50 MG TABLET [96968]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-676-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"633232-367-41","type":"NDC"}],"standard_charges":[{"gross_charge":307.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR | NDC EA = 1 VIAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [129448]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-739-12","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-445-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUCONAZOLE 100 MG TABLET [10044]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-728-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-157-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"PRAVASTATIN 10 MG TABLET [11110]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69097-788-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [130348]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733386125","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETAMINE 50 MG/ML INJECTION SOLUTION [4238]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9508-01","type":"NDC"}],"standard_charges":[{"gross_charge":17.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7751-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPHENIDATE 10 MG TABLET [4986]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-1144-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4902-34","type":"NDC"}],"standard_charges":[{"gross_charge":48.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [106364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-9045-11","type":"NDC"}],"standard_charges":[{"gross_charge":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-1020-25","type":"NDC"}],"standard_charges":[{"gross_charge":64.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NICOTINE (POLACRILEX) 2 MG GUM [10717]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0536-3029-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFPODOXIME 100 MG TABLET [9468]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-5438-20","type":"NDC"}],"standard_charges":[{"gross_charge":5.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALLOPURINOL 100 MG TABLET [310]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6571-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PRAMIPEXOLE 0.5 MG TABLET [22719]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"33342-033-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [180136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-216-01","type":"NDC"}],"standard_charges":[{"gross_charge":19.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RIVAROXABAN 10 MG TABLET [110250]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50458-580-30","type":"NDC"}],"standard_charges":[{"gross_charge":38.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HYDROMORPHONE 2 MG TABLET [3760]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-579-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHLOROPROCAINE 10 MG/ML (1 %) INJECTION SOLUTION [9523]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-475-01","type":"NDC"}],"standard_charges":[{"gross_charge":45.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"GABAPENTIN 100 MG CAPSULE [18309]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63739-591-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 10 MG TABLET [3698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-447-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYTOCIN IN LACTATED RINGERS 30 UNIT/500 ML INTRAVENOUS SOLUTION [128127]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-9008-67","type":"NDC"}],"standard_charges":[{"gross_charge":15.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [177828]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0003-2291-11","type":"NDC"}],"standard_charges":[{"gross_charge":6561.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DUPILUMAB 300 MG/2 ML SUBCUTANEOUS SYRINGE [182876]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0024-5914-00","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0248-01","type":"NDC"}],"standard_charges":[{"gross_charge":29.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 1 MG/ML INJECTION SOLUTION WRAPPER [339091]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-1010-25","type":"NDC"}],"standard_charges":[{"gross_charge":19.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-NOREPINEPHRINE INFUSION 16 MCG/ML IN D5W [440060]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3755-75","type":"NDC"}],"standard_charges":[{"gross_charge":957.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RISPERIDONE 0.25 MG TABLET [25519]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6357-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IBUPROFEN 600 MG TABLET [3844]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59651-361-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-736-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION (WIN) [339136]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"FLUOCINOLONE 0.025 % TOPICAL CREAM [3184]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"62559-289-15","type":"NDC"}],"standard_charges":[{"gross_charge":71.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-69","type":"NDC"}],"standard_charges":[{"gross_charge":32.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-284-20","type":"NDC"}],"standard_charges":[{"gross_charge":44.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-853-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [168096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-910-12","type":"NDC"}],"standard_charges":[{"gross_charge":202.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [168097]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-912-11","type":"NDC"}],"standard_charges":[{"gross_charge":284.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66758-190-06","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-434-84","type":"NDC"}],"standard_charges":[{"gross_charge":9.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV [131037]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81298-9655-1","type":"NDC"}],"standard_charges":[{"gross_charge":76.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [130005]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1542-20","type":"NDC"}],"standard_charges":[{"gross_charge":174.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [127673]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121472215","type":"NDC"}],"standard_charges":[{"gross_charge":9.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0085-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [121432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1160-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-16","type":"NDC"}],"standard_charges":[{"gross_charge":7.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10%-SODIUM CHLORIDE 10 MEQ-POTASSIUM CHLORIDE 5 MEQ INTRAVENOUS SOLUTION (NEONATAL) [975064]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-7107-09","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE WITH SMALL MASK [187721]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435188810","type":"NDC"}],"standard_charges":[{"gross_charge":108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TAPENTADOL 50 MG TABLET [98253]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"24510-050-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-161-02","type":"NDC"}],"standard_charges":[{"gross_charge":2.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"COLESTIPOL 5 GRAM ORAL PACKET [12218]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"59762-0260-1","type":"NDC"}],"standard_charges":[{"gross_charge":5.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 1 MG TABLET [6493]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60219-1705-1","type":"NDC"}],"standard_charges":[{"gross_charge":0.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6148-0","type":"NDC"}],"standard_charges":[{"gross_charge":2.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"DICYCLOMINE 10 MG CAPSULE [2418]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-369-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS [31025]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61703-342-50","type":"NDC"}],"standard_charges":[{"gross_charge":196.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-77","type":"NDC"}],"standard_charges":[{"gross_charge":13.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-567-00","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RILUZOLE 50 MG TABLET [16124]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67877-286-60","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8290306545","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"DEXTROSE 25% IN WATER (D25W) INTRAVENOUS SOLUTION [975210]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4010-75","type":"NDC"}],"standard_charges":[{"gross_charge":150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION [130758]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0009-0018-20","type":"NDC"}],"standard_charges":[{"gross_charge":169.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"LACTATED RINGERS INTRAVENOUS SOLUTION [4318]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0117-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-5921-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0469-6501-89","type":"NDC"}],"standard_charges":[{"gross_charge":713.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-415-10","type":"NDC"}],"standard_charges":[{"gross_charge":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [127625]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-116-02","type":"NDC"}],"standard_charges":[{"gross_charge":156.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"44567-707-25","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ARIPIPRAZOLE 1 MG/ML ORAL SOLUTION [40446]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"59148-013-15","type":"NDC"}],"standard_charges":[{"gross_charge":2811.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-405-79","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-29","type":"NDC"}],"standard_charges":[{"gross_charge":5.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66794-237-02","type":"NDC"}],"standard_charges":[{"gross_charge":24.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-574-00","type":"NDC"}],"standard_charges":[{"gross_charge":12.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESCITALOPRAM 10 MG TABLET [33512]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-617-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARFILZOMIB 10 MG INTRAVENOUS SOLUTION [187719]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"76075-103-01","type":"NDC"}],"standard_charges":[{"gross_charge":1567.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3302-1","type":"NDC"}],"standard_charges":[{"gross_charge":44.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE [7319]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"8452176708","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0002-8215-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISONE 20 MG TABLET [6496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0054-0018-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9157-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9577-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0185-0415-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0017-03","type":"NDC"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [119246]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-8315-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0472-0379-15","type":"NDC"}],"standard_charges":[{"gross_charge":20.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [127344]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0574-0521-74","type":"NDC"}],"standard_charges":[{"gross_charge":33.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE [27644]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7056-99","type":"NDC"}],"standard_charges":[{"gross_charge":19.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE 5 MG TABLET [10814]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10702-018-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOTREXATE SODIUM 2.5 MG TABLET [4973]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-670-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-194-10","type":"NDC"}],"standard_charges":[{"gross_charge":17.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-206-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHLORPROMAZINE 25 MG TABLET [1656]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-430-11","type":"NDC"}],"standard_charges":[{"gross_charge":7.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-487-07","type":"NDC"}],"standard_charges":[{"gross_charge":32.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ARIPIPRAZOLE 2 MG TABLET [70306]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65162-896-03","type":"NDC"}],"standard_charges":[{"gross_charge":1.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NETARSUDIL 0.02 %-LATANOPROST 0.005 % EYE DROPS [189603]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70727-529-25","type":"NDC"}],"standard_charges":[{"gross_charge":0.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-700-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0006-0277-01","type":"NDC"}],"standard_charges":[{"gross_charge":47.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9577-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":4.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ INGREDIENT ORDERABLE [425004]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1746-71","type":"NDC"}],"standard_charges":[{"gross_charge":27.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0555-0159-04","type":"NDC"}],"standard_charges":[{"gross_charge":0.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LORAZEPAM 1 MG TABLET [4573]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-0241-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 700 MG TABLET [100992]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10361-778-31","type":"NDC"}],"standard_charges":[{"gross_charge":9.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-420-20","type":"NDC"}],"standard_charges":[{"gross_charge":75.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"42858-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMITRIPTYLINE 25 MG TABLET [435]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-107-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MUPIROCIN 2 % TOPICAL OINTMENT [10674]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-1312-0","type":"NDC"}],"standard_charges":[{"gross_charge":24.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"51672-2003-6","type":"NDC"}],"standard_charges":[{"gross_charge":9.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [29858]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-390-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION [82204]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-117-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1049-2","type":"NDC"}],"standard_charges":[{"gross_charge":23.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"72578-173-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [124729]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3302-1","type":"NDC"}],"standard_charges":[{"gross_charge":40.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"CLINDAMYCIN IV 12 MG/ML IN D5W (PEDIATRIC-PREMIX) [977176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-4006-36","type":"NDC"}],"standard_charges":[{"gross_charge":0.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [14983]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-5000-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-0209-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9889-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9660-40","type":"NDC"}],"standard_charges":[{"gross_charge":21.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2723-30","type":"NDC"}],"standard_charges":[{"gross_charge":4.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3414-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"INHALATIONAL SPACING DEVICE WITH MEDIUM MASK [187722]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0456-0745-13","type":"NDC"}],"standard_charges":[{"gross_charge":139.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0720-01","type":"NDC"}],"standard_charges":[{"gross_charge":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OSELTAMIVIR 6 MG/ML ORAL SUSPENSION [110998]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0527-5137-62","type":"NDC"}],"standard_charges":[{"gross_charge":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PILOCARPINE 1 % EYE DROPS [6279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0998-0203-15","type":"NDC"}],"standard_charges":[{"gross_charge":258.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"25021-114-87","type":"NDC"}],"standard_charges":[{"gross_charge":18.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"COLCHICINE 0.6 MG TABLET [1821]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-899-30","type":"NDC"}],"standard_charges":[{"gross_charge":1.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-162-05","type":"NDC"}],"standard_charges":[{"gross_charge":3.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-077-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-33","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-BUPIVACAINE 0.25%-LIDOCAINE 1%-EPINEPHRINE 1:1,000 SYRINGE [440017]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-489-27","type":"NDC"}],"standard_charges":[{"gross_charge":5.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-815-02","type":"NDC"}],"standard_charges":[{"gross_charge":32.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"67457-553-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET [125887]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68382-529-60","type":"NDC"}],"standard_charges":[{"gross_charge":4.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9386-01","type":"NDC"}],"standard_charges":[{"gross_charge":10.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9889-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-4100-90","type":"NDC"}],"standard_charges":[{"gross_charge":18.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-04","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AA 2.75% NO.2-DEXTROSE 5 %-ELECTROLYTES NO.29 (CLINIMIX E 2.75/5) IV SOLN [27946]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-1142-03","type":"NDC"}],"standard_charges":[{"gross_charge":105.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-0901-01","type":"NDC"}],"standard_charges":[{"gross_charge":41.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION (BOLUS) [400745]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3545-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NIACIN ER 250 MG CAPSULE,EXTENDED RELEASE [5536]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"1000670020","type":"NDC"}],"standard_charges":[{"gross_charge":0.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION [186085]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"13533-318-10","type":"NDC"}],"standard_charges":[{"gross_charge":1420.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"25021-127-20","type":"NDC"}],"standard_charges":[{"gross_charge":8.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43598-405-11","type":"NDC"}],"standard_charges":[{"gross_charge":63.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51224-012-20","type":"NDC"}],"standard_charges":[{"gross_charge":976.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"55111-533-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57237-077-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14984]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-463-01","type":"NDC"}],"standard_charges":[{"gross_charge":46.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [172309]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-930-00","type":"NDC"}],"standard_charges":[{"gross_charge":63.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DAPSONE 25 MG TABLET [2132]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"64980-567-03","type":"NDC"}],"standard_charges":[{"gross_charge":2.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM IODIDE-123 CAPSULE (MILLICURIE) [464102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"99999-9101-01","type":"NDC"}],"standard_charges":[{"gross_charge":269.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 2 % MUCOSAL SOLUTION [122471]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-4950-15","type":"NDC"}],"standard_charges":[{"gross_charge":13.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9507-01","type":"NDC"}],"standard_charges":[{"gross_charge":18.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0245-5319-89","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2267-20","type":"NDC"}],"standard_charges":[{"gross_charge":10.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0703-4502-04","type":"NDC"}],"standard_charges":[{"gross_charge":6.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-3451-70","type":"NDC"}],"standard_charges":[{"gross_charge":4.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GEMFIBROZIL 600 MG TABLET [3378]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16714-101-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CINACALCET 30 MG TABLET [38100]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"16729-440-15","type":"NDC"}],"standard_charges":[{"gross_charge":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VALACYCLOVIR 500 MG TABLET [13133]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"31722-704-90","type":"NDC"}],"standard_charges":[{"gross_charge":1.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"57896-455-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL 5 MG TABLET [3583]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-161-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-373-02","type":"NDC"}],"standard_charges":[{"gross_charge":6.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"ARTIFICIAL TEARS OINTMENT WRAPPER [508109]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"6373614308","type":"NDC"}],"standard_charges":[{"gross_charge":18.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHADONE 5 MG/5 ML ORAL SOLUTION [4952]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-711-16","type":"NDC"}],"standard_charges":[{"gross_charge":136.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CETIRIZINE 5 MG/5 ML ORAL SOLUTION [97141]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-004-59","type":"NDC"}],"standard_charges":[{"gross_charge":5.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72205-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [27506]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"75907-024-11","type":"NDC"}],"standard_charges":[{"gross_charge":30.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3340-1","type":"NDC"}],"standard_charges":[{"gross_charge":29.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALPROSTADIL 500 MCG/ML INJECTION SOLUTION [9001]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-3169-01","type":"NDC"}],"standard_charges":[{"gross_charge":390.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7800-10","type":"NDC"}],"standard_charges":[{"gross_charge":10.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LENALIDOMIDE 15 MG CAPSULE [76783]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0378-1941-21","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 25 MG TABLET [37637]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6340-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENOBARBITAL 32.4 MG TABLET [6217]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6575-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0904-7325-62","type":"NDC"}],"standard_charges":[{"gross_charge":9.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"23155-688-31","type":"NDC"}],"standard_charges":[{"gross_charge":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [189176]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-620-01","type":"NDC"}],"standard_charges":[{"gross_charge":14.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [129652]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"49281-215-15","type":"NDC"}],"standard_charges":[{"gross_charge":108.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-246-58","type":"NDC"}],"standard_charges":[{"gross_charge":778.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-169-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OLANZAPINE 2.5 MG TABLET [21057]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-3110-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61924-188-08","type":"NDC"}],"standard_charges":[{"gross_charge":12.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-280-16","type":"NDC"}],"standard_charges":[{"gross_charge":7.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-700-05","type":"NDC"}],"standard_charges":[{"gross_charge":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"EPINEPHRINE 1 MG/10ML INJECTION SYRINGE [2848]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3318-1","type":"NDC"}],"standard_charges":[{"gross_charge":28.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE [125741]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"8373079830","type":"NDC"}],"standard_charges":[{"gross_charge":47.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION [7321]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7805-10","type":"NDC"}],"standard_charges":[{"gross_charge":17.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [93931]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0487-0201-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0517-0955-01","type":"NDC"}],"standard_charges":[{"gross_charge":54.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HALOPERIDOL 1 MG TABLET [3579]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-1392-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUOXETINE 10 MG CAPSULE [10069]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-5784-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CARVEDILOL 3.125 MG TABLET [18551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7305-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SIMPLE SYRUP [7242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"3172293747","type":"NDC"}],"standard_charges":[{"gross_charge":34.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MECLIZINE 12.5 MG TABLET [12024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-522-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MONTELUKAST 10 MG TABLET [22509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-556-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-251-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"METRONIDAZOLE 250 MG TABLET [5015]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-526-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"60687-662-91","type":"NDC"}],"standard_charges":[{"gross_charge":35.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CYCLOPHOSPHAMIDE 25 MG CAPSULE [169994]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62332-618-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [9466]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"64980-403-50","type":"NDC"}],"standard_charges":[{"gross_charge":164.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 250 MG CAPSULE [450]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-016-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"FLUDROCORTISONE 0.1 MG TABLET [10054]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-288-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68094-024-59","type":"NDC"}],"standard_charges":[{"gross_charge":4.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET [130560]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7733344125","type":"NDC"}],"standard_charges":[{"gross_charge":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-BUPIVACAINE 0.25%-LIDOCAINE 1% SYRINGE [440009]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"99999-9007-50","type":"NDC"}],"standard_charges":[{"gross_charge":6.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [176024]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0078-0659-20","type":"NDC"}],"standard_charges":[{"gross_charge":0.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0173-0682-24","type":"NDC"}],"standard_charges":[{"gross_charge":62.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0407-1413-63","type":"NDC"}],"standard_charges":[{"gross_charge":0.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3178-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3795-19","type":"NDC"}],"standard_charges":[{"gross_charge":2.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LORAZEPAM 2 MG/ML INJECTION SOLUTION WRAPPER [339699]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6778-05","type":"NDC"}],"standard_charges":[{"gross_charge":0.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPER) [975239]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6125-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43598-305-62","type":"NDC"}],"standard_charges":[{"gross_charge":69.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GEMFIBROZIL 600 MG TABLET [3378]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-350-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TERAZOSIN 5 MG CAPSULE [14553]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-766-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CLOZAPINE 100 MG TABLET [9647]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-922-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-165-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-262-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-65","type":"NDC"}],"standard_charges":[{"gross_charge":28.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MORPHINE 2 MG/ML INJECTION WRAPPER [339565]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-452-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM BICARBONATE 650 MG TABLET [7312]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"66553-008-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67850-150-00","type":"NDC"}],"standard_charges":[{"gross_charge":3.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68094-113-59","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-639-25","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYDROXYZINE HCL 25 MG TABLET [3774]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-5061-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9982-50","type":"NDC"}],"standard_charges":[{"gross_charge":30.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET [14087]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0406-0484-23","type":"NDC"}],"standard_charges":[{"gross_charge":1.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108130]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-2300-01","type":"NDC"}],"standard_charges":[{"gross_charge":3.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4699-54","type":"NDC"}],"standard_charges":[{"gross_charge":24.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"INHALATIONAL SPACING DEVICE WITH SMALL MASK [187721]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0435188810","type":"NDC"}],"standard_charges":[{"gross_charge":108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRIHEXYPHENIDYL 2 MG TABLET [8166]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0591-5335-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUORESCEIN 1 MG EYE STRIPS [27663]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"17238-900-99","type":"NDC"}],"standard_charges":[{"gross_charge":0.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"43386-090-19","type":"NDC"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50580-600-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TRAMADOL 50 MG TABLET [14632]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51079-991-20","type":"NDC"}],"standard_charges":[{"gross_charge":1.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [18195]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-198-30","type":"NDC"}],"standard_charges":[{"gross_charge":33.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [20040]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60687-762-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION [191429]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63459-104-50","type":"NDC"}],"standard_charges":[{"gross_charge":7221.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-094-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MONTELUKAST 10 MG TABLET [22509]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-875-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68462-157-40","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70100-424-01","type":"NDC"}],"standard_charges":[{"gross_charge":376.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":1039.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9626]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0009-6780-01","type":"NDC"}],"standard_charges":[{"gross_charge":15.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DOCUSATE SODIUM 50 MG/5ML LIQUID [36962]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0544-10","type":"NDC"}],"standard_charges":[{"gross_charge":2.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9331-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9795]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0803-04","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"VANCOMYCIN 1 GRAM/200 ML IN 0.9 % SOD. CHLORIDE INTRAVENOUS PIGGYBACK [179719]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-3583-01","type":"NDC"}],"standard_charges":[{"gross_charge":71.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AA 5% NO.6-DEXTROSE 15%-LYTES NO.23 (CLINIMIX E 5/15) IV SOLN [27963]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-7030-01","type":"NDC"}],"standard_charges":[{"gross_charge":123.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IRON SUCROSE 200 MG IRON/10 ML IV PUSH (WIN) [975062]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-2310-05","type":"NDC"}],"standard_charges":[{"gross_charge":190.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"GLUCAGON HCL 1 MG/ML INJECTION WRAPPER [339421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0548-5850-00","type":"NDC"}],"standard_charges":[{"gross_charge":526.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN BALDWIN II"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24385-352-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [168046]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-070-01","type":"NDC"}],"standard_charges":[{"gross_charge":25003.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-335-01","type":"NDC"}],"standard_charges":[{"gross_charge":118.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60505-6157-0","type":"NDC"}],"standard_charges":[{"gross_charge":5.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION [6487]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60758-119-05","type":"NDC"}],"standard_charges":[{"gross_charge":121.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"60793-701-02","type":"NDC"}],"standard_charges":[{"gross_charge":790.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-300-36","type":"NDC"}],"standard_charges":[{"gross_charge":10.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [106364]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-462-37","type":"NDC"}],"standard_charges":[{"gross_charge":33.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65219-436-02","type":"NDC"}],"standard_charges":[{"gross_charge":10.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ZOLPIDEM 5 MG TABLET [11701]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"65862-159-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71351-021-05","type":"NDC"}],"standard_charges":[{"gross_charge":2.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"PENICILLIN V POTASSIUM 250 MG TABLET [6092]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9837-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LACTATED RINGERS IV BOLUS [400296]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0264-7750-00","type":"NDC"}],"standard_charges":[{"gross_charge":9.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPRANOLOL 40 MG TABLET [6658]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0603-5484-21","type":"NDC"}],"standard_charges":[{"gross_charge":0.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0367-21","type":"NDC"}],"standard_charges":[{"gross_charge":2.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"},{"gross_charge":2.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 500 MG TABLET [102]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6730-80","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"24385-352-10","type":"NDC"}],"standard_charges":[{"gross_charge":6.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"TORSEMIDE 20 MG TABLET [18293]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50111-917-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-169-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"HYALURONATE SODIUM, STABILIZED 88 MG/4 ML INTRA-ARTICULAR SYRINGE [169356]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"5967682001","type":"NDC"}],"standard_charges":[{"gross_charge":4275.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-783-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDRALAZINE 10 MG TABLET [3698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-811-11","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-16","type":"NDC"}],"standard_charges":[{"gross_charge":4.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-PHENYLEPHRINE INFUSION 10 MG/250 ML (40 MCG/ML) IN NS (BEV) [444689]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-751-00","type":"NDC"}],"standard_charges":[{"gross_charge":862.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"HYDROMORPHONE (PF) 1 MG/ML INJECTION SOLUTION [121831]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-852-03","type":"NDC"}],"standard_charges":[{"gross_charge":8.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-020-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-351-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [193439]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68727-712-01","type":"NDC"}],"standard_charges":[{"gross_charge":23850.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"71288-433-82","type":"NDC"}],"standard_charges":[{"gross_charge":6.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0093-6816-45","type":"NDC"}],"standard_charges":[{"gross_charge":21.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1159-09","type":"NDC"}],"standard_charges":[{"gross_charge":4.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-6145-01","type":"NDC"}],"standard_charges":[{"gross_charge":0.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"MEMANTINE 10 MG TABLET [36966]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-6506-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-0493-02","type":"NDC"}],"standard_charges":[{"gross_charge":190.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET [76950]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"2055503300","type":"NDC"}],"standard_charges":[{"gross_charge":0.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXYCYCLINE HYCLATE 100 MG TABLET [2625]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"27808-234-02","type":"NDC"}],"standard_charges":[{"gross_charge":0.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"CIPROFLOXACIN 250 MG TABLET [25118]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-688-10","type":"NDC"}],"standard_charges":[{"gross_charge":0.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"62372-630-15","type":"NDC"}],"standard_charges":[{"gross_charge":14.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DIVALPROEX 125 MG TABLET,DELAYED RELEASE [2551]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"62756-796-88","type":"NDC"}],"standard_charges":[{"gross_charge":0.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-187-30","type":"NDC"}],"standard_charges":[{"gross_charge":12.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-229-05","type":"NDC"}],"standard_charges":[{"gross_charge":30.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-506-00","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE [128173]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"6425333335","type":"NDC"}],"standard_charges":[{"gross_charge":1.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CICLOPIROX 0.77 % TOPICAL CREAM [9598]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"68462-297-17","type":"NDC"}],"standard_charges":[{"gross_charge":6.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [169631]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"70010-199-05","type":"NDC"}],"standard_charges":[{"gross_charge":1.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP [252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70752-102-12","type":"NDC"}],"standard_charges":[{"gross_charge":62.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"POTASSIUM-SODIUM PHOSPHATES ORAL SUSPENSION (50 MG/ML ELEMENTARY PHOS) [978496]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"7135101001","type":"NDC"}],"standard_charges":[{"gross_charge":545.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OR-CALCIUM CHLORIDE INFUSION 6 G/60 ML [440059]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"76329-3304-1","type":"NDC"}],"standard_charges":[{"gross_charge":26.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0121-0646-10","type":"NDC"}],"standard_charges":[{"gross_charge":7.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER [175221]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0173-0882-14","type":"NDC"}],"standard_charges":[{"gross_charge":380.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DEXTROSE 10 % IV BOLUS [400302]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0023-03","type":"NDC"}],"standard_charges":[{"gross_charge":4.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % IV BOLUS [400291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-02","type":"NDC"}],"standard_charges":[{"gross_charge":1.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [121432]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1160-18","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ATROPINE 1 MG/ML INJECTION SOLUTION WRAPPER [339091]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0517-1010-25","type":"NDC"}],"standard_charges":[{"gross_charge":19.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN ENDOSCOPY"}]},{"description":"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9627]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3290-91","type":"NDC"}],"standard_charges":[{"gross_charge":12.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"BENZONATATE 100 MG CAPSULE [988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7153-61","type":"NDC"}],"standard_charges":[{"gross_charge":1.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0944-0493-04","type":"NDC"}],"standard_charges":[{"gross_charge":190.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-048-24","type":"NDC"}],"standard_charges":[{"gross_charge":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"36000-306-60","type":"NDC"}],"standard_charges":[{"gross_charge":11.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [109034]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"51754-0500-1","type":"NDC"}],"standard_charges":[{"gross_charge":10.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-163-30","type":"NDC"}],"standard_charges":[{"gross_charge":3.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"55150-169-10","type":"NDC"}],"standard_charges":[{"gross_charge":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [121872]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-089-50","type":"NDC"}],"standard_charges":[{"gross_charge":16.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-280-02","type":"NDC"}],"standard_charges":[{"gross_charge":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-406-01","type":"NDC"}],"standard_charges":[{"gross_charge":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FAT EMULSION 20 % INTRAVENOUS [10014]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"65219-533-01","type":"NDC"}],"standard_charges":[{"gross_charge":39.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"81284-611-00","type":"NDC"}],"standard_charges":[{"gross_charge":15.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [130004]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0069-1542-20","type":"NDC"}],"standard_charges":[{"gross_charge":154.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0093-3127-01","type":"NDC"}],"standard_charges":[{"gross_charge":2.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9720-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129504]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-6729-11","type":"NDC"}],"standard_charges":[{"gross_charge":10.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"10019-553-90","type":"NDC"}],"standard_charges":[{"gross_charge":52.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KETOROLAC 30 MG/ML INJECTION WRAPPER [339546]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"31722-306-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION [93052]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"32909-926-03","type":"NDC"}],"standard_charges":[{"gross_charge":0.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN UNICORN PARK"}]},{"description":"EPINEPHRINE 1 MG/ML INJECTION SOLUTION [125938]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"42023-168-01","type":"NDC"}],"standard_charges":[{"gross_charge":471.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION [129698]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"49281-250-51","type":"NDC"}],"standard_charges":[{"gross_charge":868.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WH 15A Cummings Park Drive"}]},{"description":"SOTALOL 80 MG TABLET [11421]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-724-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION [191768]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"51144-020-01","type":"NDC"}],"standard_charges":[{"gross_charge":8277.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"NABUMETONE 500 MG TABLET [10676]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-630-11","type":"NDC"}],"standard_charges":[{"gross_charge":2.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [28824]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"62559-431-30","type":"NDC"}],"standard_charges":[{"gross_charge":24.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL (DIPRIVAN) BOLUS [400740]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-65","type":"NDC"}],"standard_charges":[{"gross_charge":28.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-280-36","type":"NDC"}],"standard_charges":[{"gross_charge":5.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-489-27","type":"NDC"}],"standard_charges":[{"gross_charge":59.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68001-416-36","type":"NDC"}],"standard_charges":[{"gross_charge":44.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METHYLPHENIDATE 5 MG TABLET [4988]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"68084-805-11","type":"NDC"}],"standard_charges":[{"gross_charge":3.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"68516-5216-8","type":"NDC"}],"standard_charges":[{"gross_charge":1038.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"IOVERSOL 320 MG IODINE/ML INTRAVENOUS SYRINGE [39700]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0019-1323-00","type":"NDC"}],"standard_charges":[{"gross_charge":126.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [108096]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9022-01","type":"NDC"}],"standard_charges":[{"gross_charge":98.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95811]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9250-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0143-9378-01","type":"NDC"}],"standard_charges":[{"gross_charge":38.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [27838]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0049-31","type":"NDC"}],"standard_charges":[{"gross_charge":4.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-1778-15","type":"NDC"}],"standard_charges":[{"gross_charge":2.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"LIDOCAINE 10 MG/ML (1%) INJECTION SOLUTION WRAPPER [508024]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-4279-16","type":"NDC"}],"standard_charges":[{"gross_charge":7.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CAPTOPRIL 12.5 MG TABLET [9401]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0781-8052-01","type":"NDC"}],"standard_charges":[{"gross_charge":1.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMMONIUM LACTATE 12 % LOTION [10380]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"0904598463","type":"NDC"}],"standard_charges":[{"gross_charge":16.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TROPICAMIDE 1 % EYE DROPS [8250]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0998-0355-15","type":"NDC"}],"standard_charges":[{"gross_charge":288.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]","drug_information":{"unit":"1","type":"GM"},"code_information":[{"code":"17478-824-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TAPENTADOL ER 100 MG TABLET,EXTENDED RELEASE,12 HR [110263]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"24510-116-60","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LISINOPRIL 5 MG TABLET [10451]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"43547-352-10","type":"NDC"}],"standard_charges":[{"gross_charge":1.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"44567-437-24","type":"NDC"}],"standard_charges":[{"gross_charge":21.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"DORNASE ALFA 5 MG/30 ML STERILE WATER INTRAPLEURAL [400814]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"50242-100-39","type":"NDC"}],"standard_charges":[{"gross_charge":376.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"BETHANECHOL CHLORIDE 25 MG TABLET [1044]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"60687-700-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"63323-812-01","type":"NDC"}],"standard_charges":[{"gross_charge":16.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"72266-102-01","type":"NDC"}],"standard_charges":[{"gross_charge":5.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [184448]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"78206-162-01","type":"NDC"}],"standard_charges":[{"gross_charge":1039.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION [453]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9888-01","type":"NDC"}],"standard_charges":[{"gross_charge":4.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK [128039]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-0553-11","type":"NDC"}],"standard_charges":[{"gross_charge":9.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [5018]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0338-9541-24","type":"NDC"}],"standard_charges":[{"gross_charge":3.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0409-3300-01","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0548-5601-00","type":"NDC"}],"standard_charges":[{"gross_charge":12.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0641-0400-37","type":"NDC"}],"standard_charges":[{"gross_charge":6.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACETAMINOPHEN 325 MG TABLET [101]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-1982-61","type":"NDC"}],"standard_charges":[{"gross_charge":0.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"LABETOLOL 5 MG/ML INTRAVENOUS SOLUTION WRAPPER [339888]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-420-20","type":"NDC"}],"standard_charges":[{"gross_charge":75.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN AMBULATORY SURG CTR"}]},{"description":"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"17478-937-05","type":"NDC"}],"standard_charges":[{"gross_charge":7.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WIN FAM MED WILMINGTON"}]},{"description":"ROSUVASTATIN 10 MG TABLET [35134]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50090-3177-0","type":"NDC"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"HYDROMORPHONE 20 MG/100 ML (0.2 MG/ML) PCA (WIN) [505033]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"61553-890-48","type":"NDC"}],"standard_charges":[{"gross_charge":87.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PROPOFOL 10 MG/ML EMULSION INTRAVENOUS INFUSION [11150]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-269-78","type":"NDC"}],"standard_charges":[{"gross_charge":27.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"63323-285-04","type":"NDC"}],"standard_charges":[{"gross_charge":109.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML ORAL SUSPENSION [81428]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66689-203-08","type":"NDC"}],"standard_charges":[{"gross_charge":66.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [124737]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"66794-219-63","type":"NDC"}],"standard_charges":[{"gross_charge":52.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"67457-351-01","type":"NDC"}],"standard_charges":[{"gross_charge":13.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"KIT FOR PREPARATION OF TC-99M-SODIUM OXIDRONATE 3.15 MG IV SOLUTION [190959]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"69945-091-20","type":"NDC"}],"standard_charges":[{"gross_charge":114.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL | NDC EA = 1 MILLICURIE"}]},{"description":"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"70121-1574-1","type":"NDC"}],"standard_charges":[{"gross_charge":23.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [11573]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"83634-401-41","type":"NDC"}],"standard_charges":[{"gross_charge":14.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [5007]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0143-9873-01","type":"NDC"}],"standard_charges":[{"gross_charge":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]","drug_information":{"unit":"1","type":"ML"},"code_information":[{"code":"0781-3422-71","type":"NDC"}],"standard_charges":[{"gross_charge":8.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"METHOTREXATE SODIUM 2.5 MG TABLET [4973]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"0904-7141-10","type":"NDC"}],"standard_charges":[{"gross_charge":4.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"MONTELUKAST 5 MG CHEWABLE TABLET [22510]","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"50268-574-11","type":"NDC"}],"standard_charges":[{"gross_charge":1.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: WINCHESTER HOSPITAL"}]},{"description":"CHG FLT3 GENE ITD VARIANTS QUAN","code_information":[{"code":"0046U","type":"CDM"},{"code":"0300","type":"RC"},{"code":"0046U","type":"HCPCS"}],"standard_charges":[{"gross_charge":1265.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NPM1 (NUCLEOPHOSMIN) (EG, ACUTE MYELOID LEUKEMIA) GENE ANALYSIS, QUANTITATIVE","code_information":[{"code":"0049U","type":"CDM"},{"code":"0300","type":"RC"},{"code":"0049U","type":"HCPCS"}],"standard_charges":[{"gross_charge":1265.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN","code_information":[{"code":"0058U","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0058U","type":"HCPCS"}],"standard_charges":[{"gross_charge":932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY TREPONEMA PALLIDUM TOTAL & RPR IA QUAL","code_information":[{"code":"0064U","type":"CDM"},{"code":"0302","type":"RC"},{"code":"0064U","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT DS MCRB CLL FR DNA UNTRGT NEXT GENRJ SEQ","code_information":[{"code":"0152U","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0152U","type":"HCPCS"}],"standard_charges":[{"gross_charge":6602.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BETA AMYLOID AB40&AB42 LC-MS/MS RATIO PLASMA","code_information":[{"code":"0346U","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0346U","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NEUROFILAMENT LIGHT CHAIN DIGITAL IA PLASMA QUAN","code_information":[{"code":"0361U","type":"CDM"},{"code":"0300","type":"RC"},{"code":"0361U","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONC HL NEO GEN SEQ ALYS ALG QUAN DMT CLNL SEQ","code_information":[{"code":"0364U","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0364U","type":"HCPCS"}],"standard_charges":[{"gross_charge":6022.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TGSAP SLD ORG NEO DNA 523&RNA 55 NEXT GNRJ SEQ","code_information":[{"code":"0379U","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0379U","type":"HCPCS"}],"standard_charges":[{"gross_charge":10211.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NEURO PRKNSN CSF DETCJ MSFLD A-SYNCLN PRTN QUAL","code_information":[{"code":"0393U","type":"CDM"},{"code":"0300","type":"RC"},{"code":"0393U","type":"HCPCS"}],"standard_charges":[{"gross_charge":1623.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLYCINE RECEPTOR ALPHA1 IGG SERUM/CSF LCBA QUAL","code_information":[{"code":"0431U","type":"CDM"},{"code":"0300","type":"RC"},{"code":"0431U","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG KLHL11 ANTB SERUM/CSF CELL BINDING ASSAY QUAL","code_information":[{"code":"0432U","type":"CDM"},{"code":"0300","type":"RC"},{"code":"0432U","type":"HCPCS"}],"standard_charges":[{"gross_charge":250.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD PRIVATE","code_information":[{"code":"1100000000","type":"CDM"},{"code":"0110","type":"RC"},{"code":"1100000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1060.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD PRIVATE PATIENT REQ","code_information":[{"code":"1100000001","type":"CDM"},{"code":"0110","type":"RC"},{"code":"1100000001","type":"HCPCS"}],"standard_charges":[{"gross_charge":1385.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD PRIVATE MEDICALLY NECESSARY","code_information":[{"code":"1100000003","type":"CDM"},{"code":"0110","type":"RC"},{"code":"1100000003","type":"HCPCS"}],"standard_charges":[{"gross_charge":1385.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD PRIVATE OB","code_information":[{"code":"1120000000","type":"CDM"},{"code":"0112","type":"RC"},{"code":"1120000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":3255.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD HOSPICE PRIVATE","code_information":[{"code":"1150000000","type":"CDM"},{"code":"0115","type":"RC"},{"code":"1150000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1385.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD SEMIPRIVATE","code_information":[{"code":"1200000000","type":"CDM"},{"code":"0120","type":"RC"},{"code":"1200000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1385.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MED/SURG SEMI-PRIVATE MOTHER BABY UNIT","code_information":[{"code":"1211000000","type":"CDM"},{"code":"0121","type":"RC"},{"code":"1211000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":3255.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MED/SURG SEMI-PRIVATE ACU HIGHLAND","code_information":[{"code":"1211000001","type":"CDM"},{"code":"0121","type":"RC"},{"code":"1211000001","type":"HCPCS"}],"standard_charges":[{"gross_charge":852.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MED/SURG SEMI-PRIVATE ICU","code_information":[{"code":"1211000002","type":"CDM"},{"code":"0121","type":"RC"},{"code":"1211000002","type":"HCPCS"}],"standard_charges":[{"gross_charge":1272.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD SEMIPRIVATE OB","code_information":[{"code":"1220000000","type":"CDM"},{"code":"0122","type":"RC"},{"code":"1220000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":3255.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD SEMIPRIVATE PEDIATRIC","code_information":[{"code":"1230000000","type":"CDM"},{"code":"0123","type":"RC"},{"code":"1230000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":3182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD HOSPICE SEMIPRIVATE","code_information":[{"code":"1250000000","type":"CDM"},{"code":"0125","type":"RC"}],"standard_charges":[{"gross_charge":1385.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD HOSPITAL AT HOME","code_information":[{"code":"1610000000","type":"CDM"},{"code":"0161","type":"RC"},{"code":"1610000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1065.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD NEWBORN WELL BABY","code_information":[{"code":"1700000000","type":"CDM"},{"code":"0170","type":"RC"},{"code":"1700000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1950.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NURSERY","code_information":[{"code":"1710000000","type":"CDM"},{"code":"0171","type":"RC"},{"code":"1710000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":2030.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC R&B NURSERY - NEWBORN - LEVEL II","code_information":[{"code":"1720000000","type":"CDM"},{"code":"0172","type":"RC"},{"code":"1720000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":2358.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LEAVE OF ABSENCE","code_information":[{"code":"1800000000","type":"CDM"},{"code":"0180","type":"RC"},{"code":"1800000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD ICU","code_information":[{"code":"2000000000","type":"CDM"},{"code":"0200","type":"RC"},{"code":"2000000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":3094.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD STEP DOWN","code_information":[{"code":"2060000000","type":"CDM"},{"code":"0206","type":"RC"},{"code":"2060000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1173.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROOM AND BOARD CORONARY CARE UNIT","code_information":[{"code":"2100000000","type":"CDM"},{"code":"0210","type":"RC"},{"code":"2100000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":3094.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV INF HYDRAT INIT 31 MIN TO 1 HR","code_information":[{"code":"2600000000","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96360","type":"HCPCS"}],"standard_charges":[{"gross_charge":299.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV INF HYDRAT EA ADDL HR","code_information":[{"code":"2600000001","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96361","type":"HCPCS"}],"standard_charges":[{"gross_charge":283.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV INF THER INIT 1ST HR","code_information":[{"code":"2600000002","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96365","type":"HCPCS"}],"standard_charges":[{"gross_charge":496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV INF THER EA ADDL HR","code_information":[{"code":"2600000003","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96366","type":"HCPCS"}],"standard_charges":[{"gross_charge":408.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV INF THER ADD SEQ 1ST HR","code_information":[{"code":"2600000004","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96367","type":"HCPCS"}],"standard_charges":[{"gross_charge":283.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV INF CONCURRENT","code_information":[{"code":"2600000005","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96368","type":"HCPCS"}],"standard_charges":[{"gross_charge":239.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WARMING BLANKET UPPER","code_information":[{"code":"2700000011","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2700000011","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WARMING BLANKET LOWER","code_information":[{"code":"2700000012","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2700000012","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASCOPE 3 SLIM 3.8/1.2 CHANNEL","code_information":[{"code":"2700000033","type":"CDM"},{"code":"0270","type":"RC"}],"standard_charges":[{"gross_charge":548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GLIDESCOPE LARGE","code_information":[{"code":"2700000034","type":"CDM"},{"code":"0270","type":"RC"}],"standard_charges":[{"gross_charge":83.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GLIDESCOPE SMALL","code_information":[{"code":"2700000035","type":"CDM"},{"code":"0270","type":"RC"}],"standard_charges":[{"gross_charge":83.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASCOPE 3 5.0/2.2 CHANNEL","code_information":[{"code":"2700000036","type":"CDM"},{"code":"0270","type":"RC"}],"standard_charges":[{"gross_charge":548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FIBEROPTIC BRONCHOSCOPY","code_information":[{"code":"2700000037","type":"CDM"},{"code":"0270","type":"RC"}],"standard_charges":[{"gross_charge":632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARROW CATHETER","code_information":[{"code":"2700000038","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ON-Q CATHETER","code_information":[{"code":"2700000039","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":58.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CROUPETTE REGULAR","code_information":[{"code":"2701000001","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000001","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CROUPETTE STANDBY","code_information":[{"code":"2701000002","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000002","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ISOLETTE REGULAR","code_information":[{"code":"2701000004","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000004","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HUMIDIFIED OXYGEN REG","code_information":[{"code":"2701000006","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000006","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HUMIDIFIED OXYGEN STANDBY","code_information":[{"code":"2701000007","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000007","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HTD NEBULIZER REG","code_information":[{"code":"2701000010","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000010","type":"HCPCS"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HTD NEBULIZER STANDBY","code_information":[{"code":"2701000011","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000011","type":"HCPCS"}],"standard_charges":[{"gross_charge":13.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLD NEBULIZER REG","code_information":[{"code":"2701000013","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000013","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLD NEBULIZER STANDBY","code_information":[{"code":"2701000014","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000014","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ULTRASONIC NEBULIZER REG","code_information":[{"code":"2701000015","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000015","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HHN-HAND HELD NEBULIZER","code_information":[{"code":"2701000018","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000018","type":"HCPCS"}],"standard_charges":[{"gross_charge":24.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANOPY LARGE","code_information":[{"code":"2701000019","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000019","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DISP 02 HUMIDIFIER","code_information":[{"code":"2701000020","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000020","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DISPOSABLE USN CUP","code_information":[{"code":"2701000021","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000021","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRAC TUBE","code_information":[{"code":"2701000022","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000022","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDO TUBE","code_information":[{"code":"2701000023","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000023","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MECHANICAL PERCUSSOR","code_information":[{"code":"2701000024","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000024","type":"HCPCS"}],"standard_charges":[{"gross_charge":30.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANE","code_information":[{"code":"2701000025","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000025","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WARM N FORM","code_information":[{"code":"2701000026","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000026","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BACK SUPPORT","code_information":[{"code":"2701000027","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000027","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CERVICAL COLLAR","code_information":[{"code":"2701000028","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000028","type":"HCPCS"}],"standard_charges":[{"gross_charge":26.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRUTCHES","code_information":[{"code":"2701000029","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000029","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THERAPUTTY","code_information":[{"code":"2701000030","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000030","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WARM N FORM BELT","code_information":[{"code":"2701000031","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000031","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FABRICATION STATIC","code_information":[{"code":"2701000032","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000032","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OTHER SPLINT","code_information":[{"code":"2701000033","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000033","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LONG HANDLED SPONGE","code_information":[{"code":"2701000034","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000034","type":"HCPCS"}],"standard_charges":[{"gross_charge":10.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LONG HANDLED SHOEHORN","code_information":[{"code":"2701000035","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000035","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REACHER","code_information":[{"code":"2701000036","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000036","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SOCK AID","code_information":[{"code":"2701000037","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000037","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXERCISE BLOCK","code_information":[{"code":"2701000038","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000038","type":"HCPCS"}],"standard_charges":[{"gross_charge":7.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELASTIC SHOE LACE","code_information":[{"code":"2701000039","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000039","type":"HCPCS"}],"standard_charges":[{"gross_charge":9.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HAND EXERCISER","code_information":[{"code":"2701000040","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000040","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRESSING STICK","code_information":[{"code":"2701000041","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000041","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WEIGHTED UTENSILS","code_information":[{"code":"2701000042","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000042","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LEG LIFTER","code_information":[{"code":"2701000043","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000043","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SOFT GRIP UTENSILS","code_information":[{"code":"2701000044","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000044","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUG WITH LID","code_information":[{"code":"2701000045","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000045","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUG WITH HANDLES","code_information":[{"code":"2701000046","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000046","type":"HCPCS"}],"standard_charges":[{"gross_charge":24.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOJET 3726","code_information":[{"code":"2701000047","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000047","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOJET 5026","code_information":[{"code":"2701000048","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000048","type":"HCPCS"}],"standard_charges":[{"gross_charge":123.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOJET 7622","code_information":[{"code":"2701000049","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000049","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENA CAVA FILTER","code_information":[{"code":"2701000051","type":"CDM"},{"code":"0278","type":"RC"},{"code":"2701000051","type":"HCPCS"}],"standard_charges":[{"gross_charge":1871.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARM LYMPH WRAP","code_information":[{"code":"2701000052","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000052","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VISCOHEEL","code_information":[{"code":"2701000053","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000053","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOMET CASTBOOT","code_information":[{"code":"2701000054","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000054","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TECNOL WARM&FORM RIGD INS ONLY","code_information":[{"code":"2701000055","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000055","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FOAM ROLL 1/3 SECTION","code_information":[{"code":"2701000056","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000056","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEEL CUP","code_information":[{"code":"2701000057","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000057","type":"HCPCS"}],"standard_charges":[{"gross_charge":58.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THERABAND YEL (PER 50 YD ROLL)","code_information":[{"code":"2701000058","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000058","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LYMPHEDEMA SLEEVE","code_information":[{"code":"2701000059","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000059","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BUTTON HOOK","code_information":[{"code":"2701000060","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000060","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OXYGEN/SHIFT","code_information":[{"code":"2701000061","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000061","type":"HCPCS"}],"standard_charges":[{"gross_charge":25.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEBULAIZER","code_information":[{"code":"2701000062","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000062","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HAND HELD NEB THY","code_information":[{"code":"2701000063","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000063","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRUTCHES","code_information":[{"code":"2701000064","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000064","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMMOB SHOULDER FEM M","code_information":[{"code":"2701000065","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000065","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMMOB SHOULDER FEM K","code_information":[{"code":"2701000066","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000066","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMMOBILIZER","code_information":[{"code":"2701000067","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000067","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHEEP SKIN","code_information":[{"code":"2701000068","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000068","type":"HCPCS"}],"standard_charges":[{"gross_charge":72.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRAY LUMBAR P ADULT","code_information":[{"code":"2701000069","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000069","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SLING","code_information":[{"code":"2701000070","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000070","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT KNEE UNIVERSAL","code_information":[{"code":"2701000071","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000071","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT WRIST & ARM","code_information":[{"code":"2701000072","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000072","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRAY LUMBAR PUNCTURE","code_information":[{"code":"2701000073","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000073","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRUTCHES COMPLETE","code_information":[{"code":"2701000074","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000074","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPL-HAND ALL SIZE","code_information":[{"code":"2701000075","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000075","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT KNEE 14-16","code_information":[{"code":"2701000076","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000076","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT KNEE 16-18","code_information":[{"code":"2701000077","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000077","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT KNEE 18-20","code_information":[{"code":"2701000078","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000078","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT KNEE 20-22","code_information":[{"code":"2701000079","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000079","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHOE ORTHO","code_information":[{"code":"2701000080","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000080","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AIR BRACE-LEG","code_information":[{"code":"2701000081","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000081","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT KNEE AOA","code_information":[{"code":"2701000082","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000082","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT WRIST AND ARM","code_information":[{"code":"2701000083","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000083","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLAVICAL SPLINT","code_information":[{"code":"2701000084","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000084","type":"HCPCS"}],"standard_charges":[{"gross_charge":19.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLASS 1 M&S","code_information":[{"code":"2701000085","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000085","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLASS 2 M&S","code_information":[{"code":"2701000086","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000086","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLASS 3 M&S","code_information":[{"code":"2701000087","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000087","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLASS 4 M&S","code_information":[{"code":"2701000088","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000088","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RESUSCITATOR AMBU","code_information":[{"code":"2701000089","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000089","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHORT ARM CAST","code_information":[{"code":"2701000090","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000090","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LONG ARM CAST","code_information":[{"code":"2701000091","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000091","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPICA CAST","code_information":[{"code":"2701000092","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000092","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHORT LEG CAST","code_information":[{"code":"2701000093","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000093","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LONG LEG CAST","code_information":[{"code":"2701000094","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000094","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRACE AIR CAST","code_information":[{"code":"2701000095","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000095","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECTRODES E-STIM","code_information":[{"code":"2701000096","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000096","type":"HCPCS"}],"standard_charges":[{"gross_charge":32.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ORTHOTICS","code_information":[{"code":"2701000097","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000097","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MORGAN LENS","code_information":[{"code":"2701000098","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000098","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINGER SPLINT","code_information":[{"code":"2701000099","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000099","type":"HCPCS"}],"standard_charges":[{"gross_charge":26.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MONITOR","code_information":[{"code":"2701000101","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000101","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BARTHOLIN GLAND CATHETER","code_information":[{"code":"2701000102","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000102","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT SPECIAL 1","code_information":[{"code":"2701000103","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000103","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT SPECIAL 2","code_information":[{"code":"2701000104","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000104","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLINT SPECIAL 3","code_information":[{"code":"2701000105","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000105","type":"HCPCS"}],"standard_charges":[{"gross_charge":146.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MALLEOTRAIN ANKLE BRACE","code_information":[{"code":"2701000106","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000106","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TUBING","code_information":[{"code":"2701000107","type":"CDM"},{"code":"0271","type":"RC"},{"code":"2701000107","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROCKER KNIFE","code_information":[{"code":"2701000108","type":"CDM"},{"code":"0271","type":"RC"},{"code":"2701000108","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUCTION BRUSH","code_information":[{"code":"2701000109","type":"CDM"},{"code":"0271","type":"RC"},{"code":"2701000109","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIRDS NEST FILTER","code_information":[{"code":"2701000110","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000110","type":"HCPCS"}],"standard_charges":[{"gross_charge":2674.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TITANIUM FEMORAL FILTER","code_information":[{"code":"2701000111","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000111","type":"HCPCS"}],"standard_charges":[{"gross_charge":2983.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORACIC WEDGE","code_information":[{"code":"2701000112","type":"CDM"},{"code":"0270","type":"RC"},{"code":"2701000112","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LACERATION TRAY","code_information":[{"code":"2701000113","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000113","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHT PROBE,PERCUTANEOUS LUMBAR","code_information":[{"code":"2701000115","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000115","type":"HCPCS"}],"standard_charges":[{"gross_charge":2135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LONG PROBE,PERCUTANEOUS LUMBAR","code_information":[{"code":"2701000116","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000116","type":"HCPCS"}],"standard_charges":[{"gross_charge":2413.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRADISCAL CATHETER","code_information":[{"code":"2701000117","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000117","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEBULIZER","code_information":[{"code":"2701000118","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000118","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STERILE DRESSING 15 MIN","code_information":[{"code":"2701000119","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000119","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOTRACHEAL TUBE","code_information":[{"code":"2701000120","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000120","type":"HCPCS"}],"standard_charges":[{"gross_charge":13.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRAY CATHETER FOLEY","code_information":[{"code":"2701000121","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000121","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE MARROW TRAY","code_information":[{"code":"2701000122","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000122","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LUMBAR PUNCT TRAY","code_information":[{"code":"2701000123","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000123","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SET BONE MARROW","code_information":[{"code":"2701000124","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000124","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FEMALE CATH KIT","code_information":[{"code":"2701000125","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000125","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLLARS CERVICAL","code_information":[{"code":"2701000126","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000126","type":"HCPCS"}],"standard_charges":[{"gross_charge":26.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INF LUM PUNCT KIT","code_information":[{"code":"2701000127","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000127","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TUBE SALEM SUMP","code_information":[{"code":"2701000128","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000128","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXTERNAL PACER PADS","code_information":[{"code":"2701000129","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000129","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LACERATION TRAY","code_information":[{"code":"2701000130","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2701000130","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSURE DEV, VASC, IMP/INSERT","code_information":[{"code":"2701000131","type":"CDM"},{"code":"0278","type":"RC"},{"code":"2701000131","type":"HCPCS"}],"standard_charges":[{"gross_charge":786.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRAY CONT EPIDURAL","code_information":[{"code":"2720000062","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000062","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AIRWAY EXCHANGE CATH COOK YELLOW G06732","code_information":[{"code":"2720000068","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000068","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPATCH SMALL DISK 1IN 4MM","code_information":[{"code":"2720000081","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000081","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPATCH LARGE DISK 1IN 7MM","code_information":[{"code":"2720000082","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000082","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TUBE TRACH GUIDE GUM ELAST BOUGIE","code_information":[{"code":"2720000083","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000083","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SENSOR BIS QUATRO XP PLATFORM","code_information":[{"code":"2720000084","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000084","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV FLUID WARMER RANGER","code_information":[{"code":"2720000097","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000097","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIAC OUTPUT SETUP","code_information":[{"code":"2720000099","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000099","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CENTRAL VEIN KIT TRIPLE LUMEN","code_information":[{"code":"2720000100","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000100","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEEDLE SPINAL SPROTTE 25G 5IN PENCIL","code_information":[{"code":"2720000104","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000104","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC Q2 MULTIPORT MANIFOLD 6 GANG FOR VIP","code_information":[{"code":"2720000124","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000124","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TUBE ENDOBRONCH LEFT 37FR DL ETT","code_information":[{"code":"2720000130","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000130","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TUBE ENDOBRONCH LEFT 39FR DL ETT","code_information":[{"code":"2720000131","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000131","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LMA SUPREME SIZE 4","code_information":[{"code":"2720000138","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000138","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LMA SUPREME SIZE 5","code_information":[{"code":"2720000139","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000139","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LMA UNIQUE SIZE 4","code_information":[{"code":"2720000149","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000149","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LMA UNIQUE SIZE 5","code_information":[{"code":"2720000150","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000150","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH ARROW NERVE BLOCK","code_information":[{"code":"2720000158","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000158","type":"HCPCS"}],"standard_charges":[{"gross_charge":19.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC O2 SENSOR","code_information":[{"code":"2720000180","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000180","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUCTION VALVE","code_information":[{"code":"2720000182","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000182","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FOAM HEAD SUPPORT","code_information":[{"code":"2720000202","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000202","type":"HCPCS"}],"standard_charges":[{"gross_charge":21.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PAJUNK SONO TAP CANNULA 22G 80MM","code_information":[{"code":"2720000213","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000213","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PAJUNK SONO TAP CANNULA 22G 50MM","code_information":[{"code":"2720000214","type":"CDM"},{"code":"0272","type":"RC"},{"code":"2720000214","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RUSCH TRULITE MAC 3 DISPOSABLE BLADE","code_information":[{"code":"2720000228","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RUSCH TRULITE MAC 4 DISPOSABLE BLADE","code_information":[{"code":"2720000229","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRULITE DISO MIL 2","code_information":[{"code":"2720000230","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRULITE DISO MIL 3","code_information":[{"code":"2720000231","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADULT LG SUPERNO2VA W HYPERINFLATION BAG","code_information":[{"code":"2720000233","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":83.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADULT MED SUPERNO2VA W HYPERINFLATION BAG","code_information":[{"code":"2720000234","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":83.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ON-Q PUMP PAIN 400ML","code_information":[{"code":"2720000235","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A4306","type":"HCPCS"}],"standard_charges":[{"gross_charge":570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MASK NASAL ADULT LG SUPERNO2VA 20/CA 137922","code_information":[{"code":"2720000236","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MASK NASAL ADULT MED SUPERNO2VA 20/CA 137923","code_information":[{"code":"2720000237","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MASK POM ELITE 3010318LT (129679)","code_information":[{"code":"2720000238","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PACK ROOM INH02705 (123770)","code_information":[{"code":"2720000245","type":"CDM"},{"code":"0272","type":"RC"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH, INF, PER/CENT/MIDLINE","code_information":[{"code":"2720000279","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":397.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATHETER, GUIDING","code_information":[{"code":"2720000280","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1887","type":"HCPCS"}],"standard_charges":[{"gross_charge":453.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO/SHEATH, NON-LASER","code_information":[{"code":"2720000281","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1894","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH INDW FOLEY 2 WAY LATEX - EACH","code_information":[{"code":"2720000282","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A4338","type":"HCPCS"}],"standard_charges":[{"gross_charge":3.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH INDW FOLEY 2 WAY SILICN - EACH","code_information":[{"code":"2720000283","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A4344","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH INDW FOLEY 3 WAY - EACH","code_information":[{"code":"2720000284","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A4346","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERMITTENT URINARY CATH","code_information":[{"code":"2720000285","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A4353","type":"HCPCS"}],"standard_charges":[{"gross_charge":7.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HYDROCOLLD DRG >16<=48 W/BDR","code_information":[{"code":"2720000286","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A6238","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH, BAL DIL, NON-VASCULAR","code_information":[{"code":"2720000287","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1726","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATHETER, URETERAL","code_information":[{"code":"2720000288","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1758","type":"HCPCS"}],"standard_charges":[{"gross_charge":13.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GUIDE WIRE","code_information":[{"code":"2720000289","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":32.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRACHEOSTOMY INNER CANNULA","code_information":[{"code":"2720000290","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A4623","type":"HCPCS"}],"standard_charges":[{"gross_charge":4.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRACH/LARYN TUBE NON-CUFFED","code_information":[{"code":"2720000291","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A7520","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRACH/LARYN TUBE CUFFED","code_information":[{"code":"2720000292","type":"CDM"},{"code":"0272","type":"RC"},{"code":"A7521","type":"HCPCS"}],"standard_charges":[{"gross_charge":73.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH, EP, 19 OR FEW ELECT","code_information":[{"code":"2720000293","type":"CDM"},{"code":"0272","type":"RC"},{"code":"C1730","type":"HCPCS"}],"standard_charges":[{"gross_charge":1532.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM EO STATIC","code_information":[{"code":"2740000018","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3702","type":"HCPCS"}],"standard_charges":[{"gross_charge":336.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM EWHO STATIC","code_information":[{"code":"2740000019","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3763","type":"HCPCS"}],"standard_charges":[{"gross_charge":880.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM WHFO DYNAMIC","code_information":[{"code":"2740000021","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3806","type":"HCPCS"}],"standard_charges":[{"gross_charge":523.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PREFAB WHFO STATIC","code_information":[{"code":"2740000022","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3807","type":"HCPCS"}],"standard_charges":[{"gross_charge":292.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM WHFO STATIC","code_information":[{"code":"2740000023","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3808","type":"HCPCS"}],"standard_charges":[{"gross_charge":495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM WHO STATIC","code_information":[{"code":"2740000025","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3906","type":"HCPCS"}],"standard_charges":[{"gross_charge":556.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HAND FINGER ORTHOTIC (L3913) CUSTOM STATIC","code_information":[{"code":"2740000026","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3913","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM FO STATIC","code_information":[{"code":"2740000027","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3933","type":"HCPCS"}],"standard_charges":[{"gross_charge":277.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CUSTOM HO STATIC","code_information":[{"code":"2740000031","type":"CDM"},{"code":"0274","type":"RC"},{"code":"L3919","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 276 V2632","code_information":[{"code":"2760000000","type":"CDM"},{"code":"0276","type":"RC"},{"code":"V2632","type":"HCPCS"}],"standard_charges":[{"gross_charge":368.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 278 C2639","code_information":[{"code":"2780000013","type":"CDM"},{"code":"0278","type":"RC"},{"code":"C2639","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 278 A4648","code_information":[{"code":"2780000022","type":"CDM"},{"code":"0278","type":"RC"},{"code":"A4648","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PORT, INDWELLING, IMPLANTABLE","code_information":[{"code":"2780000243","type":"CDM"},{"code":"0278","type":"RC"},{"code":"C1788","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH, DRAINAGE","code_information":[{"code":"2780000244","type":"CDM"},{"code":"0278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADHESION BARRIER","code_information":[{"code":"2780000246","type":"CDM"},{"code":"0278","type":"RC"},{"code":"C1765","type":"HCPCS"}],"standard_charges":[{"gross_charge":677.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLLECT OF VENOUS BLOOD VENIPUNCTURE","code_information":[{"code":"3000000000","type":"CDM"},{"code":"0300","type":"RC"},{"code":"36415","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLLECT OF CAPILLARY BLOOD SPECIMEN","code_information":[{"code":"3000000001","type":"CDM"},{"code":"0300","type":"RC"},{"code":"36416","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COURTESY COLLECT OF VENOUS BLOOD VENIPUNCTURE","code_information":[{"code":"3000000002","type":"CDM"},{"code":"0300","type":"RC"},{"code":"36415","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FERTILITY COLLECT OF VENOUS BLOOD VENIPUNCTURE","code_information":[{"code":"3000000003","type":"CDM"},{"code":"0300","type":"RC"},{"code":"36415","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHG FECAL OCCULT BLOOD TEST FOBT","code_information":[{"code":"3010000000","type":"CDM"},{"code":"0305","type":"RC"},{"code":"G0328","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSA ANTIGEN SCREENING","code_information":[{"code":"3010000001","type":"CDM"},{"code":"0301","type":"RC"},{"code":"G0103","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC QUAL OR QUANT ALL SOURCES INCLDS SPEC VALID TESTING PER DAY 1 TO 7 DRUG CLASS(ES)","code_information":[{"code":"3010000027","type":"CDM"},{"code":"0301","type":"RC"},{"code":"G0480","type":"HCPCS"}],"standard_charges":[{"gross_charge":734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC QUAL OR QUANT ALL SOURCES INCLDS SPEC VALID TESTING PER DAY 8 TO 14 DRUG CLASS(ES)","code_information":[{"code":"3010000028","type":"CDM"},{"code":"0301","type":"RC"},{"code":"G0481","type":"HCPCS"}],"standard_charges":[{"gross_charge":470.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HC QUAL OR QUANT ALL SOURCES INCLDS SPEC VALID TESTING PER DAY 22 OR MORE DRUG CLASS(ES)","code_information":[{"code":"3010000030","type":"CDM"},{"code":"0301","type":"RC"},{"code":"G0483","type":"HCPCS"}],"standard_charges":[{"gross_charge":938.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEURO CSF DETCJ PRION PRTN QUAKG CONF CONV QUAL","code_information":[{"code":"3010000032","type":"CDM"},{"code":"0301","type":"RC"},{"code":"0035U","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COL-CHR/MS QUAN 1 STATIONARY&MOBILE PHASE NES","code_information":[{"code":"3010000034","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INF AGNT DETECT BY DNA OR RNA HPV HIGH TO RISK TYPES FOR CRVCL CNCR SCREEN IN ADTN TO PAP","code_information":[{"code":"3060000000","type":"CDM"},{"code":"0306","type":"RC"},{"code":"G0476","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRGT GEN SEQ ALYS CCA&NONSM LNG NEO DNA&RNA 1-23","code_information":[{"code":"3100000004","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0022U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC JAK2 GENE ANALYSIS TRGT SEQ ALYS EXONS 12-15","code_information":[{"code":"3100000005","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0027U","type":"HCPCS"}],"standard_charges":[{"gross_charge":459.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RX METAB WARFARIN RX RESPONSE TRGT SEQ ALYS","code_information":[{"code":"3100000006","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0030U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRGT GEN SEQ ALYS SLD ORGN NEO DNA 324 GENES","code_information":[{"code":"3100000007","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0037U","type":"HCPCS"}],"standard_charges":[{"gross_charge":10603.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM","code_information":[{"code":"3100000008","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0041U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG","code_information":[{"code":"3100000009","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0042U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM","code_information":[{"code":"3100000010","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0043U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG","code_information":[{"code":"3100000011","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0044U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ONC BRST DUX CARC IS MRNA 12 GENES ALG RSK SCOR","code_information":[{"code":"3100000012","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0045U","type":"HCPCS"}],"standard_charges":[{"gross_charge":11732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ONC PRST8 MRNA GEN XPRS PRFL 17 GEN ALG RSK SCOR","code_information":[{"code":"3100000013","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0047U","type":"HCPCS"}],"standard_charges":[{"gross_charge":11732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LPOPRTN BLD W/5 MAJ CLASS AUTO PRFL UCENTRFUGTN","code_information":[{"code":"3100000014","type":"CDM"},{"code":"0310","type":"RC"},{"code":"0052U","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMMUNOCHEMISTRY-EA ADDL AB STAIN","code_information":[{"code":"3120000008","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMMNOFLUOR PER SPEC EA ADTL SNGL ANTIBODY STAIN PRCD ADD ON CODE","code_information":[{"code":"3120000012","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":191.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGICAL PATH PROSTATE NEEDLE BIOPSY","code_information":[{"code":"3140000000","type":"CDM"},{"code":"0310","type":"RC"},{"code":"G0416","type":"HCPCS"}],"standard_charges":[{"gross_charge":1272.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY EXAM EYE DETECT FOREIGN BODY","code_information":[{"code":"3200000000","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70030","type":"HCPCS"}],"standard_charges":[{"gross_charge":626.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY MANDIBLE PRTL UP TO 4 VIEWS","code_information":[{"code":"3200000001","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70100","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY MANDIBLE COMPL MIN 4 VIEWS","code_information":[{"code":"3200000002","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70110","type":"HCPCS"}],"standard_charges":[{"gross_charge":479.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY EXAM MASTOIDS LESS THAN 3 VIEWS PER SIDE","code_information":[{"code":"3200000003","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70120","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY MASTOID COMPL MIN 3 VIEWS PER SIDE","code_information":[{"code":"3200000004","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70130","type":"HCPCS"}],"standard_charges":[{"gross_charge":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY INTERNAL AUDITORY MEATI COMPL","code_information":[{"code":"3200000005","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70134","type":"HCPCS"}],"standard_charges":[{"gross_charge":272.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY FACIAL BONES LESS THAN 3 VIEWS","code_information":[{"code":"3200000006","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70140","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY FACIAL BONES COMP MIN 3 VIEWS","code_information":[{"code":"3200000007","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70150","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY NASAL BONES COMP MIN 3 VIEWS","code_information":[{"code":"3200000008","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70160","type":"HCPCS"}],"standard_charges":[{"gross_charge":430.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY OPTIC FORAMINA","code_information":[{"code":"3200000009","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70190","type":"HCPCS"}],"standard_charges":[{"gross_charge":211.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ORBITS COMPL MIN 4 VIEWS","code_information":[{"code":"3200000010","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70200","type":"HCPCS"}],"standard_charges":[{"gross_charge":347.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SINUSES PARANASAL LESS THAN 3 VIEWS","code_information":[{"code":"3200000011","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70210","type":"HCPCS"}],"standard_charges":[{"gross_charge":345.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SINUSES PARANASAL COMPL MIN 3 VIEWS","code_information":[{"code":"3200000012","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70220","type":"HCPCS"}],"standard_charges":[{"gross_charge":455.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SELLA TURCICA","code_information":[{"code":"3200000013","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70240","type":"HCPCS"}],"standard_charges":[{"gross_charge":301.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SKULL LESS THAN 4 VIEWS","code_information":[{"code":"3200000014","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70250","type":"HCPCS"}],"standard_charges":[{"gross_charge":474.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SKULL MIN 4 VIEWS","code_information":[{"code":"3200000015","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70260","type":"HCPCS"}],"standard_charges":[{"gross_charge":558.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY TMJ JT OPEN AND CLOSED BILAT","code_information":[{"code":"3200000016","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70330","type":"HCPCS"}],"standard_charges":[{"gross_charge":374.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY NECK SOFT TISSUE","code_information":[{"code":"3200000018","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70360","type":"HCPCS"}],"standard_charges":[{"gross_charge":474.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SALIVARY GLAND CALCULUS","code_information":[{"code":"3200000019","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70380","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIALOGRAPHY","code_information":[{"code":"3200000020","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70390","type":"HCPCS"}],"standard_charges":[{"gross_charge":958.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY RIBS UNILAT 2 VIEWS","code_information":[{"code":"3200000023","type":"CDM"},{"code":"0320","type":"RC"},{"code":"71100","type":"HCPCS"}],"standard_charges":[{"gross_charge":504.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY RIB UNILAT W POSTEROANT CH MIN 3 VIEWS","code_information":[{"code":"3200000024","type":"CDM"},{"code":"0320","type":"RC"},{"code":"71101","type":"HCPCS"}],"standard_charges":[{"gross_charge":466.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY RIB BILAT 3 VIEWS","code_information":[{"code":"3200000025","type":"CDM"},{"code":"0320","type":"RC"},{"code":"71110","type":"HCPCS"}],"standard_charges":[{"gross_charge":567.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY RIB BILAT W POSTEROANT CH MIN 4 VIEWS","code_information":[{"code":"3200000026","type":"CDM"},{"code":"0320","type":"RC"},{"code":"71111","type":"HCPCS"}],"standard_charges":[{"gross_charge":341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY STERNUM MIN 2 VIEWS","code_information":[{"code":"3200000027","type":"CDM"},{"code":"0320","type":"RC"},{"code":"71120","type":"HCPCS"}],"standard_charges":[{"gross_charge":452.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY STERNOCLAVICULAR JT(S) MIN 3 VIEWS","code_information":[{"code":"3200000028","type":"CDM"},{"code":"0320","type":"RC"},{"code":"71130","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE 1 VIEW SPECIFY LEVEL","code_information":[{"code":"3200000030","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72020","type":"HCPCS"}],"standard_charges":[{"gross_charge":291.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE CERVICAL 2 OR 3 VIEWS","code_information":[{"code":"3200000031","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72040","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE CERVICAL 4 OR 5 VIEWS","code_information":[{"code":"3200000032","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72050","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE CERVICAL 6 OR MORE VIEWS","code_information":[{"code":"3200000033","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72052","type":"HCPCS"}],"standard_charges":[{"gross_charge":378.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE THORACIC 2 VIEWS","code_information":[{"code":"3200000035","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72070","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE THORACIC 3 VIEWS","code_information":[{"code":"3200000036","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72072","type":"HCPCS"}],"standard_charges":[{"gross_charge":398.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE THORACIC MIN 4 VIEWS","code_information":[{"code":"3200000037","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72074","type":"HCPCS"}],"standard_charges":[{"gross_charge":355.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE THORACOLUMBAR 2 VIEWS","code_information":[{"code":"3200000038","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72080","type":"HCPCS"}],"standard_charges":[{"gross_charge":309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE LUMBOSACRAL 2 OR 3 VIEWS","code_information":[{"code":"3200000039","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72100","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE LUMBOSACRAL MIN 4 VIEWS","code_information":[{"code":"3200000040","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72110","type":"HCPCS"}],"standard_charges":[{"gross_charge":567.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE LUMBOSACRAL COMPL W BENDING MIN 6 VIEWS","code_information":[{"code":"3200000041","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72114","type":"HCPCS"}],"standard_charges":[{"gross_charge":381.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SPINE LUMBOSACRAL BENDING 2 OR 3 VIEWS","code_information":[{"code":"3200000042","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72120","type":"HCPCS"}],"standard_charges":[{"gross_charge":360.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY PELVIS 1 OR 2 VIEWS","code_information":[{"code":"3200000043","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72170","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY PELVIS COMPL MIN 3 VIEWS","code_information":[{"code":"3200000044","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72190","type":"HCPCS"}],"standard_charges":[{"gross_charge":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SACROILIAC JOINTS LESS 1 OR 2 VIEWS","code_information":[{"code":"3200000045","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72200","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SACROILIAC JOINTS MIN 3 VIEWS","code_information":[{"code":"3200000046","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72202","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SACRUM COCCYX MIN 2 VIEWS","code_information":[{"code":"3200000047","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72220","type":"HCPCS"}],"standard_charges":[{"gross_charge":437.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYELOGRAPHY CERVICAL","code_information":[{"code":"3200000048","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72240","type":"HCPCS"}],"standard_charges":[{"gross_charge":1376.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYELOGRAPHY LUMBOSACRAL","code_information":[{"code":"3200000050","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72265","type":"HCPCS"}],"standard_charges":[{"gross_charge":2231.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DISKOGRAPHY LUMBAR","code_information":[{"code":"3200000054","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72295","type":"HCPCS"}],"standard_charges":[{"gross_charge":6985.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY CLAVICLE COMPL","code_information":[{"code":"3200000055","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73000","type":"HCPCS"}],"standard_charges":[{"gross_charge":302.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SCAPULA COMPL","code_information":[{"code":"3200000056","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73010","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SHOULDER 1 VIEW","code_information":[{"code":"3200000057","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73020","type":"HCPCS"}],"standard_charges":[{"gross_charge":416.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SHOULDER COMPL MIN 2 VIEWS","code_information":[{"code":"3200000058","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73030","type":"HCPCS"}],"standard_charges":[{"gross_charge":416.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ARTHRO SHOULDER","code_information":[{"code":"3200000059","type":"CDM"},{"code":"0322","type":"RC"},{"code":"73040","type":"HCPCS"}],"standard_charges":[{"gross_charge":1311.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY AC JOINT BILAT W WO WEIGHTED DISTRC","code_information":[{"code":"3200000060","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73050","type":"HCPCS"}],"standard_charges":[{"gross_charge":352.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY HUMERUS MIN 2 VIEWS","code_information":[{"code":"3200000061","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73060","type":"HCPCS"}],"standard_charges":[{"gross_charge":302.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ELBOW 2 VIEWS","code_information":[{"code":"3200000062","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73070","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ELBOW COMPL MIN 3 VIEWS","code_information":[{"code":"3200000063","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73080","type":"HCPCS"}],"standard_charges":[{"gross_charge":440.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY FOREARM 2 VIEWS","code_information":[{"code":"3200000064","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73090","type":"HCPCS"}],"standard_charges":[{"gross_charge":463.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY UPPER EXTREMITY INFANT MIN 2 VIEWS","code_information":[{"code":"3200000065","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73092","type":"HCPCS"}],"standard_charges":[{"gross_charge":319.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY WRIST 2 VIEWS","code_information":[{"code":"3200000066","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73100","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY WRIST COMPL MIN 3 VIEWS","code_information":[{"code":"3200000067","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73110","type":"HCPCS"}],"standard_charges":[{"gross_charge":422.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY HAND 2 VIEWS","code_information":[{"code":"3200000068","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73120","type":"HCPCS"}],"standard_charges":[{"gross_charge":325.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY HAND MIN 3 VIEWS","code_information":[{"code":"3200000069","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73130","type":"HCPCS"}],"standard_charges":[{"gross_charge":422.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY FINGER MIN 2 VIEWS","code_information":[{"code":"3200000070","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73140","type":"HCPCS"}],"standard_charges":[{"gross_charge":424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X-RAY HIP ARTHROGRAPHY","code_information":[{"code":"3200000074","type":"CDM"},{"code":"0322","type":"RC"},{"code":"73525","type":"HCPCS"}],"standard_charges":[{"gross_charge":1323.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY KNEE 1 OR 2 VIEWS","code_information":[{"code":"3200000078","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73560","type":"HCPCS"}],"standard_charges":[{"gross_charge":404.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY KNEE 3 VIEWS","code_information":[{"code":"3200000079","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73562","type":"HCPCS"}],"standard_charges":[{"gross_charge":483.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY KNEE COMPL MIN 4 VIEWS","code_information":[{"code":"3200000080","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73564","type":"HCPCS"}],"standard_charges":[{"gross_charge":483.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY BILAT KNEE STANDING AP","code_information":[{"code":"3200000081","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73565","type":"HCPCS"}],"standard_charges":[{"gross_charge":360.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY TIBIA AND FIBULA 2 VIEWS","code_information":[{"code":"3200000082","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73590","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY LOWER EXTREMITY INFANT MIN 2 VIEWS","code_information":[{"code":"3200000083","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73592","type":"HCPCS"}],"standard_charges":[{"gross_charge":305.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ANKLE 2 VIEWS","code_information":[{"code":"3200000084","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73600","type":"HCPCS"}],"standard_charges":[{"gross_charge":325.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ANKLE COMPL MIN 3 VIEWS","code_information":[{"code":"3200000085","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73610","type":"HCPCS"}],"standard_charges":[{"gross_charge":398.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY FOOT 2 VIEWS","code_information":[{"code":"3200000086","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73620","type":"HCPCS"}],"standard_charges":[{"gross_charge":368.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY FOOT COMPL MIN 3 VIEWS","code_information":[{"code":"3200000087","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73630","type":"HCPCS"}],"standard_charges":[{"gross_charge":436.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY CALCANEUS MIN 2 VIEWS","code_information":[{"code":"3200000088","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73650","type":"HCPCS"}],"standard_charges":[{"gross_charge":441.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY TOE MIN 2 VIEWS","code_information":[{"code":"3200000089","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73660","type":"HCPCS"}],"standard_charges":[{"gross_charge":348.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ABD COMPL AQT ABD W S E D VIEWS 1 VIEW CH","code_information":[{"code":"3200000093","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74022","type":"HCPCS"}],"standard_charges":[{"gross_charge":409.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY PHARYNX AND CERVICAL ESOPHAGUS","code_information":[{"code":"3200000094","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74210","type":"HCPCS"}],"standard_charges":[{"gross_charge":431.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ESOPHAGUS","code_information":[{"code":"3200000095","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74220","type":"HCPCS"}],"standard_charges":[{"gross_charge":431.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SWALLOWING FUNC W CINERADIOGRAPHY VIDRADIOG","code_information":[{"code":"3200000096","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74230","type":"HCPCS"}],"standard_charges":[{"gross_charge":599.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY GI TRACT UPPER W WO DELAYED FILMS WO KUB","code_information":[{"code":"3200000097","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74240","type":"HCPCS"}],"standard_charges":[{"gross_charge":431.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY GI W WO GLUCAGON DELAY FILMS WO KUB","code_information":[{"code":"3200000100","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74246","type":"HCPCS"}],"standard_charges":[{"gross_charge":611.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY SML INTSTINE MULTI FILMS","code_information":[{"code":"3200000103","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74250","type":"HCPCS"}],"standard_charges":[{"gross_charge":638.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY COLON BARIUM ENEMA W WO KUB","code_information":[{"code":"3200000105","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74270","type":"HCPCS"}],"standard_charges":[{"gross_charge":775.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY COLON W SPEC HI DNS BARIUM W WO GLUCAGON","code_information":[{"code":"3200000106","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74280","type":"HCPCS"}],"standard_charges":[{"gross_charge":1658.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHOLECYSTOGRAM ORAL CONTRST","code_information":[{"code":"3200000108","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74290","type":"HCPCS"}],"standard_charges":[{"gross_charge":355.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHOLANGIOGRAPHY PANCREATOGRAPHY INTRAOP","code_information":[{"code":"3200000110","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74300","type":"HCPCS"}],"standard_charges":[{"gross_charge":584.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSCOPIC CATH BILIARY DUCTAL SYS","code_information":[{"code":"3200000115","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74328","type":"HCPCS"}],"standard_charges":[{"gross_charge":865.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMBINE ENDO CATH BILIARY PANCREATIC DUCTAL SYS","code_information":[{"code":"3200000116","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74330","type":"HCPCS"}],"standard_charges":[{"gross_charge":1312.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSHEPATC DILAT BILIARY DUCT STRICTURE","code_information":[{"code":"3200000119","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74363","type":"HCPCS"}],"standard_charges":[{"gross_charge":1415.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UROGRAPHY IV W WO KUB W WO TOMOGRAPHY","code_information":[{"code":"3200000120","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74400","type":"HCPCS"}],"standard_charges":[{"gross_charge":775.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UROGRAPHY INFUSION DRIP BOLUS TECHNIQUE","code_information":[{"code":"3200000121","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74410","type":"HCPCS"}],"standard_charges":[{"gross_charge":775.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UROGRAPHY INFUSION DRIP BOLUS TECHQ W WO TOMO","code_information":[{"code":"3200000122","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74415","type":"HCPCS"}],"standard_charges":[{"gross_charge":796.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UROGRAPHY RETROGRADE W WO KUB","code_information":[{"code":"3200000123","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74420","type":"HCPCS"}],"standard_charges":[{"gross_charge":1507.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UROGRAPHY ANTEGRADE","code_information":[{"code":"3200000124","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74425","type":"HCPCS"}],"standard_charges":[{"gross_charge":1193.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTOGRAPHY MIN 3 VIEWS","code_information":[{"code":"3200000125","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74430","type":"HCPCS"}],"standard_charges":[{"gross_charge":805.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC URETHROCYSTOGRAPHY RETROGRADE","code_information":[{"code":"3200000128","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74450","type":"HCPCS"}],"standard_charges":[{"gross_charge":865.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC URETHROCYSTOGRAPHY VOIDING","code_information":[{"code":"3200000129","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74455","type":"HCPCS"}],"standard_charges":[{"gross_charge":775.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE NEPHROMSTOMY URETER","code_information":[{"code":"3200000132","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74485","type":"HCPCS"}],"standard_charges":[{"gross_charge":5823.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HYSTEROSALPINGOGRAPHY","code_information":[{"code":"3200000133","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74740","type":"HCPCS"}],"standard_charges":[{"gross_charge":1468.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AORTOGRAPHY THORACIC SERIALOGRAPHY","code_information":[{"code":"3200000135","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75605","type":"HCPCS"}],"standard_charges":[{"gross_charge":9903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AORTOGRAPHY ABD SERIALOGRAPHY","code_information":[{"code":"3200000136","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75625","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AORTOGRAPHY ABD BI ILIOFEM LOW EXTREM CATH","code_information":[{"code":"3200000137","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75630","type":"HCPCS"}],"standard_charges":[{"gross_charge":8581.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY SPINAL SELECTIVE","code_information":[{"code":"3200000138","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75705","type":"HCPCS"}],"standard_charges":[{"gross_charge":11467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY EXTREMITY UNILAT","code_information":[{"code":"3200000139","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75710","type":"HCPCS"}],"standard_charges":[{"gross_charge":8581.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY EXTREMITY BILAT","code_information":[{"code":"3200000140","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75716","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY VISCERAL SELECTIVE SUPRASELECTIVE","code_information":[{"code":"3200000141","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75726","type":"HCPCS"}],"standard_charges":[{"gross_charge":10362.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY PELVIC SELECTIVE SUPRASELECTIVE","code_information":[{"code":"3200000142","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75736","type":"HCPCS"}],"standard_charges":[{"gross_charge":9903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY PULMONARY UNILAT SELECTIVE","code_information":[{"code":"3200000143","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75741","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY SELECTIVE EA VESSEL STUDIED AFTER BASIC XM","code_information":[{"code":"3200000145","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75774","type":"HCPCS"}],"standard_charges":[{"gross_charge":2093.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOGRAPHY EXTREMITY UNILAT","code_information":[{"code":"3200000146","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75820","type":"HCPCS"}],"standard_charges":[{"gross_charge":1902.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOGRAPHY EXTREMITY BILAT","code_information":[{"code":"3200000147","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75822","type":"HCPCS"}],"standard_charges":[{"gross_charge":2302.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY","code_information":[{"code":"3200000148","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75825","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY","code_information":[{"code":"3200000149","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75827","type":"HCPCS"}],"standard_charges":[{"gross_charge":2470.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOGRAPHY RENAL BILAT SELECTIVE","code_information":[{"code":"3200000150","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75833","type":"HCPCS"}],"standard_charges":[{"gross_charge":7782.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSHEPATC PORTGRAPHY HEMODYN EVAL","code_information":[{"code":"3200000152","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75885","type":"HCPCS"}],"standard_charges":[{"gross_charge":10735.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEPATIC VNGRPH WDG FR HEMODYN EVAL","code_information":[{"code":"3200000154","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75889","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEPATIC VNGRPH WDG FR WO HEMODYN EVAL","code_information":[{"code":"3200000155","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75891","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOUS SAMPLING THROUGH CATH W WO ANGIOGRAPHY","code_information":[{"code":"3200000156","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75893","type":"HCPCS"}],"standard_charges":[{"gross_charge":9903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH THER EMBOLIZATION ANY METHOD","code_information":[{"code":"3200000157","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75894","type":"HCPCS"}],"standard_charges":[{"gross_charge":5240.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY CATH FOLLOW UP STUDY TRANSCATH THER","code_information":[{"code":"3200000159","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75898","type":"HCPCS"}],"standard_charges":[{"gross_charge":2536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH BIOPSY","code_information":[{"code":"3200000163","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75970","type":"HCPCS"}],"standard_charges":[{"gross_charge":1187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHANGE LOCAL TUBE DRAINAGE CATH W CONTRAST","code_information":[{"code":"3200000167","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75984","type":"HCPCS"}],"standard_charges":[{"gross_charge":756.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGICAL GUIDANCE PERC DRG W PLMT CATH","code_information":[{"code":"3200000168","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75989","type":"HCPCS"}],"standard_charges":[{"gross_charge":1351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLUORO UP TO 1 HR","code_information":[{"code":"3200000169","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76000","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X-RAY FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHILD","code_information":[{"code":"3200000171","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76010","type":"HCPCS"}],"standard_charges":[{"gross_charge":305.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY ABSCESS FISTULA SINUS TRACT","code_information":[{"code":"3200000172","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76080","type":"HCPCS"}],"standard_charges":[{"gross_charge":958.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X-RAY SURGICAL SPECIMEN","code_information":[{"code":"3200000173","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76098","type":"HCPCS"}],"standard_charges":[{"gross_charge":2166.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLUOROSCOPIC CENTRAL VENOUS ACCESS DEV PLACEMENT","code_information":[{"code":"3200000175","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77001","type":"HCPCS"}],"standard_charges":[{"gross_charge":206.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT","code_information":[{"code":"3200000176","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77002","type":"HCPCS"}],"standard_charges":[{"gross_charge":256.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLUOROSCOPIC  NEEDLE CATH SPINE PARASPINAL DIAG THER","code_information":[{"code":"3200000177","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77003","type":"HCPCS"}],"standard_charges":[{"gross_charge":366.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE","code_information":[{"code":"3200000178","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77053","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE AGE STUDIES","code_information":[{"code":"3200000180","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77072","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE LENGTH STUDIES","code_information":[{"code":"3200000181","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77073","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY OSSEOUS SURVEY LTD","code_information":[{"code":"3200000182","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77074","type":"HCPCS"}],"standard_charges":[{"gross_charge":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY OSSEOUS SURVEY COMPL","code_information":[{"code":"3200000183","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77075","type":"HCPCS"}],"standard_charges":[{"gross_charge":600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X RAY OSSEOUS SURVEY INFANT","code_information":[{"code":"3200000184","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77076","type":"HCPCS"}],"standard_charges":[{"gross_charge":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DXA BONE DENSITY STUDY 1 OR MORE SITES AXIAL SKEL","code_information":[{"code":"3200000185","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77080","type":"HCPCS"}],"standard_charges":[{"gross_charge":537.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DXA BONE DENSITY STUDY 1 OR MORE SITES APPENDICLR SKEL","code_information":[{"code":"3200000186","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77081","type":"HCPCS"}],"standard_charges":[{"gross_charge":368.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIOGRAPHY ILIAC ARTERY W CARDIAC CATH","code_information":[{"code":"3200000188","type":"CDM"},{"code":"0481","type":"RC"},{"code":"G0278","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X-RAY HEAD FOR ORTHODONTIA","code_information":[{"code":"3200000196","type":"CDM"},{"code":"0320","type":"RC"},{"code":"70350","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X-RAY,C/T,DISK,SUPERV/INTERPRET","code_information":[{"code":"3200000199","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72285","type":"HCPCS"}],"standard_charges":[{"gross_charge":6985.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROGRAM OF ELBOW","code_information":[{"code":"3200000200","type":"CDM"},{"code":"0322","type":"RC"},{"code":"73085","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROGRAM OF WRIST","code_information":[{"code":"3200000201","type":"CDM"},{"code":"0322","type":"RC"},{"code":"73115","type":"HCPCS"}],"standard_charges":[{"gross_charge":1445.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROGRAM OF KNEE JOINT","code_information":[{"code":"3200000202","type":"CDM"},{"code":"0322","type":"RC"},{"code":"73580","type":"HCPCS"}],"standard_charges":[{"gross_charge":1284.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROGRAM OF ANKLE","code_information":[{"code":"3200000203","type":"CDM"},{"code":"0322","type":"RC"},{"code":"73615","type":"HCPCS"}],"standard_charges":[{"gross_charge":1478.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LYMPHANGIO ABD/PELV BILAT","code_information":[{"code":"3200000211","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75807","type":"HCPCS"}],"standard_charges":[{"gross_charge":3846.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOGRAM RENAL UNILAT","code_information":[{"code":"3200000213","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75831","type":"HCPCS"}],"standard_charges":[{"gross_charge":6899.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE,OBST MATL,CVA DEV VIA SEP VEN ACC","code_information":[{"code":"3200000217","type":"CDM"},{"code":"0320","type":"RC"},{"code":"75901","type":"HCPCS"}],"standard_charges":[{"gross_charge":436.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC X-RAY TOMOGRAM","code_information":[{"code":"3200000220","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76100","type":"HCPCS"}],"standard_charges":[{"gross_charge":453.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC JOINT SURVEY, SINGLE VIEW","code_information":[{"code":"3200000224","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77077","type":"HCPCS"}],"standard_charges":[{"gross_charge":278.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DXA BONE DENSITY STUDY AXIAL SKELETON","code_information":[{"code":"3200000225","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77085","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VERTEBRAL FRACTURE ASSESSMENT VIA DXA","code_information":[{"code":"3200000226","type":"CDM"},{"code":"0320","type":"RC"},{"code":"77086","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYELOGRAM CERVICAL","code_information":[{"code":"3200000227","type":"CDM"},{"code":"0320","type":"RC"},{"code":"62302","type":"HCPCS"}],"standard_charges":[{"gross_charge":1638.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYELOGRAM THORACIC","code_information":[{"code":"3200000228","type":"CDM"},{"code":"0320","type":"RC"},{"code":"62303","type":"HCPCS"}],"standard_charges":[{"gross_charge":1600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYELOGRAM LUMBOSACRAL","code_information":[{"code":"3200000229","type":"CDM"},{"code":"0320","type":"RC"},{"code":"62304","type":"HCPCS"}],"standard_charges":[{"gross_charge":1638.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYELOGRAM 2 OR MORE REGION","code_information":[{"code":"3200000230","type":"CDM"},{"code":"0320","type":"RC"},{"code":"62305","type":"HCPCS"}],"standard_charges":[{"gross_charge":1600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM SPINE ENTIRE THORACIC & LUMBAR INC SKULL CERVCL & SCRL SPINE IF PRFRMD 1 VIEW","code_information":[{"code":"3200000231","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72081","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM SPINE ENTIRE THORACIC & LUMBAR INC SKULL CERVCL & SCRL SPINE IF PRFRMD 2 OR 3 VIEWS","code_information":[{"code":"3200000232","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72082","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM SPINE ENTIRE THORACIC & LUMBAR INC SKULL CERVCL & SCRL SPINE IF PRFRMD 4 OR 5 VIEWS","code_information":[{"code":"3200000233","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72083","type":"HCPCS"}],"standard_charges":[{"gross_charge":610.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM SPINE ENTIRE THORACIC & LUMBAR INC SKULL CERVCL & SCRL SPINE IF PRFRMD 6+ VIEWS","code_information":[{"code":"3200000234","type":"CDM"},{"code":"0320","type":"RC"},{"code":"72084","type":"HCPCS"}],"standard_charges":[{"gross_charge":406.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM HIP UNILATERAL W PELVIS PRFRMD 1 VIEW","code_information":[{"code":"3200000235","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73501","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM HIP UNILATERAL W PELVIS PRFRMD 2 TO 3 VIEWS","code_information":[{"code":"3200000236","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73502","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM HIP BILAT W PELVIS PRFRMD 2 VIEWS","code_information":[{"code":"3200000238","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73521","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM HIP BILAT W PELVIS PRFRMD 3 TO 4 VIEWS","code_information":[{"code":"3200000239","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73522","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM HIP BILAT W PELVIS PRFRMD MINIMUM OF 5 VIEWS","code_information":[{"code":"3200000240","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73523","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM FEMUR 1 VIEW","code_information":[{"code":"3200000241","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73551","type":"HCPCS"}],"standard_charges":[{"gross_charge":468.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD EXAM FEMUR MINIMUM 2 VIEWS","code_information":[{"code":"3200000242","type":"CDM"},{"code":"0320","type":"RC"},{"code":"73552","type":"HCPCS"}],"standard_charges":[{"gross_charge":468.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM ESOPHAGUS DOUBLE CONTRAST STUDY","code_information":[{"code":"3200000244","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74221","type":"HCPCS"}],"standard_charges":[{"gross_charge":653.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY","code_information":[{"code":"3200000245","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74248","type":"HCPCS"}],"standard_charges":[{"gross_charge":1773.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRE-PLAN 3D MODEL W/CCTA","code_information":[{"code":"3200000267","type":"CDM"},{"code":"0320","type":"RC"},{"code":"C9793","type":"HCPCS"}],"standard_charges":[{"gross_charge":3159.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABL PERC CRYO IMG GUID NRV PLX","code_information":[{"code":"3200000268","type":"CDM"},{"code":"0320","type":"RC"},{"code":"0442T","type":"HCPCS"}],"standard_charges":[{"gross_charge":19884.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR SAFETY IMPLANT&/FB ASSMT CLIN STAF 1ST 15 MIN","code_information":[{"code":"3200000269","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76014","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR SAFETY IMPLANT&/FB ASSMT CLIN STAFF EA ADD 30","code_information":[{"code":"3200000270","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76015","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR SAFETY DETERMINATION PHYSICIAN/OTHER QHP","code_information":[{"code":"3200000271","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76016","type":"HCPCS"}],"standard_charges":[{"gross_charge":273.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR SAFETY MED PHYSICS XM CUSTOMIZATION PLNG&MNTR","code_information":[{"code":"3200000272","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76017","type":"HCPCS"}],"standard_charges":[{"gross_charge":750.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR SAFETY IMPLANT ELECTRONICS PREPJ SUPVJ PHYS/QHP","code_information":[{"code":"3200000273","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76018","type":"HCPCS"}],"standard_charges":[{"gross_charge":348.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR SAFETY IMPLANT POS&/IMMOBLJ SUPVJ PHYS/QHP","code_information":[{"code":"3200000274","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76019","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  SIM ANG W/PRS CATH RAD EMB","code_information":[{"code":"3200000275","type":"CDM"},{"code":"0320","type":"RC"},{"code":"C8004","type":"HCPCS"}],"standard_charges":[{"gross_charge":35213.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 3D BN IMG ALGOR DRVD FR MRI","code_information":[{"code":"3200000276","type":"CDM"},{"code":"0320","type":"RC"},{"code":"G0566","type":"HCPCS"}],"standard_charges":[{"gross_charge":485.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLUOROSCOPY","code_information":[{"code":"3201000000","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76496","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CALLBACK MAMMO","code_information":[{"code":"3201000003","type":"CDM"},{"code":"0401","type":"RC"},{"code":"77065","type":"HCPCS"}],"standard_charges":[{"gross_charge":387.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIO PULMON BILAT SELECT","code_information":[{"code":"3230000001","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75743","type":"HCPCS"}],"standard_charges":[{"gross_charge":6560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANGIO PULMON BILAT NONSELEC","code_information":[{"code":"3230000002","type":"CDM"},{"code":"0323","type":"RC"},{"code":"75746","type":"HCPCS"}],"standard_charges":[{"gross_charge":2809.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM CHEST SINGLE VIEW","code_information":[{"code":"3240000006","type":"CDM"},{"code":"0324","type":"RC"},{"code":"71045","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM CHEST 2 VIEWS","code_information":[{"code":"3240000007","type":"CDM"},{"code":"0324","type":"RC"},{"code":"71046","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM CHEST 3 VIEWS","code_information":[{"code":"3240000008","type":"CDM"},{"code":"0324","type":"RC"},{"code":"71047","type":"HCPCS"}],"standard_charges":[{"gross_charge":254.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM CHEST 4+ VIEWS","code_information":[{"code":"3240000009","type":"CDM"},{"code":"0324","type":"RC"},{"code":"71048","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM ABDOMEN 1 VIEW","code_information":[{"code":"3240000010","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74018","type":"HCPCS"}],"standard_charges":[{"gross_charge":351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM ABDOMEN 2 VIEWS","code_information":[{"code":"3240000011","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74019","type":"HCPCS"}],"standard_charges":[{"gross_charge":507.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RADIOLOGIC EXAM ABDOMEN 3+ VIEWS","code_information":[{"code":"3240000012","type":"CDM"},{"code":"0320","type":"RC"},{"code":"74021","type":"HCPCS"}],"standard_charges":[{"gross_charge":355.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM EVICORE","code_information":[{"code":"3290000001","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1001","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM MEDCURRENT","code_information":[{"code":"3290000002","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1002","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM MEDICALIS","code_information":[{"code":"3290000003","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1003","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM NDSC","code_information":[{"code":"3290000004","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1004","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM AIM","code_information":[{"code":"3290000007","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1007","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM CRANBERRY PK","code_information":[{"code":"3290000008","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1008","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM STANSON","code_information":[{"code":"3290000010","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1010","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM QUALIFIED NOS","code_information":[{"code":"3290000011","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1011","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM AGILEMD","code_information":[{"code":"3290000012","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1012","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM EVIDENCECARE","code_information":[{"code":"3290000013","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1013","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM INVENIQA","code_information":[{"code":"3290000014","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1014","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM RELIANT","code_information":[{"code":"3290000015","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1015","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM SPEED OF CARE","code_information":[{"code":"3290000016","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1016","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM HEALTHHELP","code_information":[{"code":"3290000017","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1017","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM INFINIX","code_information":[{"code":"3290000018","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1018","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CDSM LOGICNETS","code_information":[{"code":"3290000019","type":"CDM"},{"code":"0329","type":"RC"},{"code":"G1019","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RESPIRATORY MOTION MANAGEMENT SIMULATION","code_information":[{"code":"3300000000","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77293","type":"HCPCS"}],"standard_charges":[{"gross_charge":994.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD TREAT 1MEV OR MORE COMPLEX","code_information":[{"code":"3300000001","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77412","type":"HCPCS"}],"standard_charges":[{"gross_charge":940.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN SUBC IM NON HORMONAL ANTI NEO","code_information":[{"code":"3310000000","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96401","type":"HCPCS"}],"standard_charges":[{"gross_charge":540.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN SUBC IM HORMONAL ANTI NEO","code_information":[{"code":"3310000001","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96402","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN IV PUSH TECH SINGLE DRUG","code_information":[{"code":"3310000002","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96409","type":"HCPCS"}],"standard_charges":[{"gross_charge":737.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN IV PUSH TECH EA ADDL DRUG","code_information":[{"code":"3310000003","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96411","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER RAD SIMULA AIDED FIELD SETTING SIMPLE","code_information":[{"code":"3330000000","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77280","type":"HCPCS"}],"standard_charges":[{"gross_charge":827.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER RAD SIMULA AIDED FIELD SETTING INTERMED","code_information":[{"code":"3330000001","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77285","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER RAD SIMULA AIDED FIELD SETTING COMPLEX","code_information":[{"code":"3330000002","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77290","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 3D RADIOTHERAPY PLAN DOSE VOL HISTOGRAMS","code_information":[{"code":"3330000003","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77295","type":"HCPCS"}],"standard_charges":[{"gross_charge":6842.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BASIC RADIATION DOSIMETRY CALCULATION","code_information":[{"code":"3330000004","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77300","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTENSITY MODUL RADIAT THER PLAN DOSE VOL HISTOS","code_information":[{"code":"3330000005","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77301","type":"HCPCS"}],"standard_charges":[{"gross_charge":6842.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPECIAL TELETHERAPY PORT PLAN","code_information":[{"code":"3330000009","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77321","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPECIAL DOSIMETRY PRESCRIBED BY TREATING PHYS","code_information":[{"code":"3330000012","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77331","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRTMT DEVICES DESIGN AND CONSTRUCTION SIMPLE","code_information":[{"code":"3330000013","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77332","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRTMT DEVICES DESIGN AND CONSTRUCTION INTERMED","code_information":[{"code":"3330000014","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77333","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRTMT DEVICES DESIGN AND CONSTRUCTION COMPLEX","code_information":[{"code":"3330000015","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77334","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONTINUING MEDICAL PHYSICS CONSULT PER WK","code_information":[{"code":"3330000016","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77336","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MLC IMRT DESIGN AND CONSTRUCTION PER IMRT PLAN","code_information":[{"code":"3330000017","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77338","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPECIAL MEDICAL RADIATION PHYSICS CONSULT","code_information":[{"code":"3330000018","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77370","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STEREOTACTIC BODY RADIATION DELIVERY","code_information":[{"code":"3330000020","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77373","type":"HCPCS"}],"standard_charges":[{"gross_charge":8960.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UNLISTED MEDICAL RAD DOSIMETRY TRTMT DEV SPEC SVCS","code_information":[{"code":"3330000021","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77399","type":"HCPCS"}],"standard_charges":[{"gross_charge":684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER RADIOLOGY PORT FILMS","code_information":[{"code":"3330000028","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77417","type":"HCPCS"}],"standard_charges":[{"gross_charge":423.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STEREOTACTIC BODY RADIATION MANIPAGEMENT","code_information":[{"code":"3330000031","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77435","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPECIAL TRTMT PROC","code_information":[{"code":"3330000032","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77470","type":"HCPCS"}],"standard_charges":[{"gross_charge":2932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERSTITIAL RADIATION SOURCE APPLIC COMPLEX","code_information":[{"code":"3330000033","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77778","type":"HCPCS"}],"standard_charges":[{"gross_charge":6171.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUPERVISION HANDLING LOADING RADIATION SOURCE","code_information":[{"code":"3330000037","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77790","type":"HCPCS"}],"standard_charges":[{"gross_charge":376.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL","code_information":[{"code":"3330000040","type":"CDM"},{"code":"0333","type":"RC"},{"code":"55920","type":"HCPCS"}],"standard_charges":[{"gross_charge":15327.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TELE ISODOSE PLN SIM W DOSIMETRY CALC","code_information":[{"code":"3330000049","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77306","type":"HCPCS"}],"standard_charges":[{"gross_charge":1792.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TELE ISODOSE PLN COMP W BASIC DOSIMETRY","code_information":[{"code":"3330000050","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77307","type":"HCPCS"}],"standard_charges":[{"gross_charge":1792.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRACHYTX ISODOSE PLN SIM W DOSIMETRY CALC","code_information":[{"code":"3330000051","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77316","type":"HCPCS"}],"standard_charges":[{"gross_charge":1629.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRACHYTX ISODOSE PLN INTERMED W DOSIMETRY CALC","code_information":[{"code":"3330000052","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77317","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRACHYTX ISODOSE PLN COMP W DOSIMETRY CALC","code_information":[{"code":"3330000053","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77318","type":"HCPCS"}],"standard_charges":[{"gross_charge":1955.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTENSITY MODUL RADIATION TX DELV SIM","code_information":[{"code":"3330000054","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77385","type":"HCPCS"}],"standard_charges":[{"gross_charge":2932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTENSITY MODULATED RADIATION TX DELV COMP","code_information":[{"code":"3330000055","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77386","type":"HCPCS"}],"standard_charges":[{"gross_charge":2932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GUID FOR LOC OF TARGET VOL RADIA TX DELV","code_information":[{"code":"3330000056","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77387","type":"HCPCS"}],"standard_charges":[{"gross_charge":326.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD TRMT DLVRY =>1 MEV SIMPLE","code_information":[{"code":"3330000057","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77402","type":"HCPCS"}],"standard_charges":[{"gross_charge":564.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RAD TRMT DELVRY >= 1 MEV INTERM","code_information":[{"code":"3330000060","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77407","type":"HCPCS"}],"standard_charges":[{"gross_charge":937.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECTRONIC BRACHYTHERAPY HIGH DOSE PER FRACTION INC DOSIMETRY","code_information":[{"code":"3330000081","type":"CDM"},{"code":"0333","type":"RC"},{"code":"0395T","type":"HCPCS"}],"standard_charges":[{"gross_charge":2117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CS-TREATMENT PLAN,INTERMEDIATE","code_information":[{"code":"3331000003","type":"CDM"},{"code":"0333","type":"RC"},{"code":"77262","type":"HCPCS"}],"standard_charges":[{"gross_charge":397.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMO INTRA ARTERIAL PUSH TECH","code_information":[{"code":"3331000004","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96420","type":"HCPCS"}],"standard_charges":[{"gross_charge":1280.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN PRTL CAVITY PORT CATH","code_information":[{"code":"3331000005","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96446","type":"HCPCS"}],"standard_charges":[{"gross_charge":673.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN CNS REQ SPINAL PUNCTURE","code_information":[{"code":"3331000006","type":"CDM"},{"code":"0331","type":"RC"},{"code":"96450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1432.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REFILL AND MAINT IMPLANT PUMP DRUG DEL SPINAL BRAIN","code_information":[{"code":"3350000000","type":"CDM"},{"code":"0335","type":"RC"},{"code":"95990","type":"HCPCS"}],"standard_charges":[{"gross_charge":1064.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REFILL AND MAINT IMPLANT PUMP DRUG DEL SOINAL WITH PHYS","code_information":[{"code":"3350000001","type":"CDM"},{"code":"0335","type":"RC"},{"code":"95991","type":"HCPCS"}],"standard_charges":[{"gross_charge":7442.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN IV INFUSION TECH 1ST HR SINGLE DRUG","code_information":[{"code":"3350000002","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96413","type":"HCPCS"}],"standard_charges":[{"gross_charge":1274.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN IV INFUSION TECH EA ADDL HR","code_information":[{"code":"3350000003","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96415","type":"HCPCS"}],"standard_charges":[{"gross_charge":428.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN TECH PROLONGED INFUSION PUMP","code_information":[{"code":"3350000004","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96416","type":"HCPCS"}],"standard_charges":[{"gross_charge":1274.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN TECH EA ADDL INFUSION","code_information":[{"code":"3350000005","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96417","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN INTRA ARTERIAL INFUSION TECH 1ST HR","code_information":[{"code":"3350000006","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96422","type":"HCPCS"}],"standard_charges":[{"gross_charge":1317.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN INTRA ARTERIAL INFUSION EA ADDL HR","code_information":[{"code":"3350000007","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96423","type":"HCPCS"}],"standard_charges":[{"gross_charge":345.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMOTHERAPY ADMIN INTRA ARTERIAL PROLONGED INFUSION","code_information":[{"code":"3350000008","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96425","type":"HCPCS"}],"standard_charges":[{"gross_charge":1251.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REFILL AND MAINT PORTABLE PUMP","code_information":[{"code":"3350000009","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96521","type":"HCPCS"}],"standard_charges":[{"gross_charge":1096.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REFILL AND MAINT PUMP DRUG DEL SYS","code_information":[{"code":"3350000010","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96522","type":"HCPCS"}],"standard_charges":[{"gross_charge":799.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMO INFUSION CONCURRENT","code_information":[{"code":"3350000011","type":"CDM"},{"code":"0335","type":"RC"},{"code":"96549","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SALIVARY GLAND IMAGING SERIAL IMAGES","code_information":[{"code":"3400000000","type":"CDM"},{"code":"0340","type":"RC"},{"code":"78231","type":"HCPCS"}],"standard_charges":[{"gross_charge":748.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THYROID UPTAKE SINGLE MULT QUANT MS","code_information":[{"code":"3410000000","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78012","type":"HCPCS"}],"standard_charges":[{"gross_charge":670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THYROID IMAGE W VASCULAR FLOW","code_information":[{"code":"3410000001","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78013","type":"HCPCS"}],"standard_charges":[{"gross_charge":700.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THYROID UPTAKE W BLD FLOW SINGLE MULT QUANT MS","code_information":[{"code":"3410000002","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78014","type":"HCPCS"}],"standard_charges":[{"gross_charge":1030.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PARATHYROID PLANAR IMAGE","code_information":[{"code":"3410000005","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78070","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PARATHYROID PLANAR IMAGE W WO SUBTRACTION","code_information":[{"code":"3410000006","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78071","type":"HCPCS"}],"standard_charges":[{"gross_charge":1699.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LYMPHATICS LYMPH NODES IMAGE","code_information":[{"code":"3410000008","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78195","type":"HCPCS"}],"standard_charges":[{"gross_charge":1039.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIVER AND SPLEEN IMAGE STATIC ONLY","code_information":[{"code":"3410000012","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78215","type":"HCPCS"}],"standard_charges":[{"gross_charge":860.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIVER AND SPLEEN IMAGE W VASCULAR FLOW","code_information":[{"code":"3410000013","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78216","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEPATOBIL SYS IMAGE INCL GALLBLADDER","code_information":[{"code":"3410000014","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78226","type":"HCPCS"}],"standard_charges":[{"gross_charge":1626.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEPATOBIL SYS IMAGE INCL GALLBLADDER W RX INTERVENTION","code_information":[{"code":"3410000015","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78227","type":"HCPCS"}],"standard_charges":[{"gross_charge":1256.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GASTRIC EMPTYING STUDY","code_information":[{"code":"3410000017","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78264","type":"HCPCS"}],"standard_charges":[{"gross_charge":1139.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ACUTE GASTROINTESTINAL BLD LOSS IMAGE","code_information":[{"code":"3410000020","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78278","type":"HCPCS"}],"standard_charges":[{"gross_charge":764.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTESTINE IMAGE","code_information":[{"code":"3410000021","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78290","type":"HCPCS"}],"standard_charges":[{"gross_charge":748.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE AND OR JOINT IMAGE LTD AREA","code_information":[{"code":"3410000022","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78300","type":"HCPCS"}],"standard_charges":[{"gross_charge":748.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE AND OR JOINT IMAGE WHOLE BODY","code_information":[{"code":"3410000024","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78306","type":"HCPCS"}],"standard_charges":[{"gross_charge":906.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE AND OR JOINT 3 PHASE STUDY","code_information":[{"code":"3410000025","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78315","type":"HCPCS"}],"standard_charges":[{"gross_charge":982.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIAC SHUNT DETECTION","code_information":[{"code":"3410000027","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78428","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON CARDIAC VASCULAR FLOW IMAGE","code_information":[{"code":"3410000028","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78445","type":"HCPCS"}],"standard_charges":[{"gross_charge":735.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS","code_information":[{"code":"3410000029","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78451","type":"HCPCS"}],"standard_charges":[{"gross_charge":3172.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOCARDIAL PERFUSION PLANAR 1 STUDY REST OR STRESS","code_information":[{"code":"3410000030","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78453","type":"HCPCS"}],"standard_charges":[{"gross_charge":3172.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES","code_information":[{"code":"3410000031","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78454","type":"HCPCS"}],"standard_charges":[{"gross_charge":3172.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARD BLD POOL GATED PLANAR 1 STUDY REST STRESS","code_information":[{"code":"3410000035","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78472","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARD BLD POOL GATED MULT STUDY WAL MOTN EJECT FRACTURE","code_information":[{"code":"3410000036","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78473","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARD BLD POOL GATED SPECT REST WAL MOTN EJECT FRACT","code_information":[{"code":"3410000037","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78494","type":"HCPCS"}],"standard_charges":[{"gross_charge":1408.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PULMONARY VENTILATION IMAGE","code_information":[{"code":"3410000038","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78579","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PULMONARY PERFUSION IMAGE PARTICULATE","code_information":[{"code":"3410000039","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78580","type":"HCPCS"}],"standard_charges":[{"gross_charge":707.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PULMONARY VENTILATION AND PERFUSION IMAGE","code_information":[{"code":"3410000040","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78582","type":"HCPCS"}],"standard_charges":[{"gross_charge":1476.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC QUANT DIFF PULM PERFUSION W WO IMAGE","code_information":[{"code":"3410000041","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78597","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC QUANT DIFF PULM PRFUSION AND VENT W WO IMAGE","code_information":[{"code":"3410000042","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78598","type":"HCPCS"}],"standard_charges":[{"gross_charge":1377.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CEREBROSPINAL FLUID FLOW WO MATERIAL CISTERNOGRAPHY","code_information":[{"code":"3410000045","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78630","type":"HCPCS"}],"standard_charges":[{"gross_charge":1229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KIDNEY IMAGE MORPHOLOGY","code_information":[{"code":"3410000048","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78700","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KIDNEY IMAGE MORPHOLOGY VASCULAR FLOW 1 WO RX","code_information":[{"code":"3410000050","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78707","type":"HCPCS"}],"standard_charges":[{"gross_charge":1423.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KIDNEY IMAGE MORPHOLOGY VASCULAR FLOW 1 W RX","code_information":[{"code":"3410000051","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78708","type":"HCPCS"}],"standard_charges":[{"gross_charge":962.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KIDNEY IMAGE MORPHOLOGY VASCULAR FLOW MULTIPLE","code_information":[{"code":"3410000052","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78709","type":"HCPCS"}],"standard_charges":[{"gross_charge":1256.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC URETERAL REFLUX STUDY RP VOIDING CYSTOGRAM","code_information":[{"code":"3410000054","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78740","type":"HCPCS"}],"standard_charges":[{"gross_charge":962.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TESTICULAR IMAGE W VASCULAR FLOW","code_information":[{"code":"3410000055","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78761","type":"HCPCS"}],"standard_charges":[{"gross_charge":962.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RP LOCAL TUMOR DSTRB AGENT WHOLE BODY 1 DAY","code_information":[{"code":"3410000058","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78802","type":"HCPCS"}],"standard_charges":[{"gross_charge":2231.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RP LOCAL TUMOR DSTRB AGENT TOMOG SPECT","code_information":[{"code":"3410000059","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78803","type":"HCPCS"}],"standard_charges":[{"gross_charge":2231.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RP LOCAL TUMOR DSTRB AGENT WHOLE BODY 2 OR MORE DAYS","code_information":[{"code":"3410000060","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78804","type":"HCPCS"}],"standard_charges":[{"gross_charge":3171.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ RP LOCAL NON-IMAGE PROBE STUDY INTRAVENOUS","code_information":[{"code":"3410000064","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78808","type":"HCPCS"}],"standard_charges":[{"gross_charge":1408.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOCARDIAL SPECT MULTIPLE STUDIES","code_information":[{"code":"3410000067","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78452","type":"HCPCS"}],"standard_charges":[{"gross_charge":3323.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PARATHYROID IMAGING W/TOMOGRAPHIC SPECT & CT","code_information":[{"code":"3410000070","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78072","type":"HCPCS"}],"standard_charges":[{"gross_charge":1472.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE MINERAL, DUAL PHOTON","code_information":[{"code":"3410000074","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78351","type":"HCPCS"}],"standard_charges":[{"gross_charge":347.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEART FIRST PASS SINGLE,PLANAR","code_information":[{"code":"3410000077","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78481","type":"HCPCS"}],"standard_charges":[{"gross_charge":1056.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RP LOCLZJ TUM SPECT W CT 1 AREA 1 DAY IMAGING","code_information":[{"code":"3410000079","type":"CDM"},{"code":"0341","type":"RC"},{"code":"78830","type":"HCPCS"}],"standard_charges":[{"gross_charge":3619.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RP THERAPY ORAL ADMIN","code_information":[{"code":"3420000000","type":"CDM"},{"code":"0342","type":"RC"},{"code":"79005","type":"HCPCS"}],"standard_charges":[{"gross_charge":1452.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT HEAD BRAIN WO CONTRAST MATERIAL","code_information":[{"code":"3500000000","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT HEAD BRAIN W CONTRAST MATERIAL","code_information":[{"code":"3500000001","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70460","type":"HCPCS"}],"standard_charges":[{"gross_charge":1000.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT HEAD BRAIN W WO CONTRAST MATERIAL","code_information":[{"code":"3500000002","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70470","type":"HCPCS"}],"standard_charges":[{"gross_charge":1204.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ORBIT SELLA POST FOSSA EAR WO CONTRAST MATERIAL","code_information":[{"code":"3500000003","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70480","type":"HCPCS"}],"standard_charges":[{"gross_charge":1309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ORBIT SELLA POST FOSSA EAR W CONTRAST MATERIAL","code_information":[{"code":"3500000004","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70481","type":"HCPCS"}],"standard_charges":[{"gross_charge":870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ORBIT SELLA POST FOSSA EAR W WO CONTRAST MATERIAL","code_information":[{"code":"3500000005","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70482","type":"HCPCS"}],"standard_charges":[{"gross_charge":1144.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT MAXILLOFACIAL WO CONTRAST MATERIAL","code_information":[{"code":"3500000006","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70486","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT MAXILLOFACIAL W CONTRAST MATERIAL","code_information":[{"code":"3500000007","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70487","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT MAXILLOFACIAL W WO CONTRAST MATERIAL","code_information":[{"code":"3500000008","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70488","type":"HCPCS"}],"standard_charges":[{"gross_charge":1002.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT SOFT TISSUE NECK WO CONTRAST MATERIAL","code_information":[{"code":"3500000009","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70490","type":"HCPCS"}],"standard_charges":[{"gross_charge":1238.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT SOFT TISSUE NECK W CONTRAST MATERIAL","code_information":[{"code":"3500000010","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70491","type":"HCPCS"}],"standard_charges":[{"gross_charge":1474.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT SOFT TISSUE NECK W WO CONTRAST MATERIAL","code_information":[{"code":"3500000011","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70492","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY HEAD W WO CONTRAST MATERIAL","code_information":[{"code":"3500000012","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70496","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY NECK W WO CONTRAST MATERIAL","code_information":[{"code":"3500000013","type":"CDM"},{"code":"0351","type":"RC"},{"code":"70498","type":"HCPCS"}],"standard_charges":[{"gross_charge":1082.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORAX WO CONTRAST MATERIAL","code_information":[{"code":"3500000014","type":"CDM"},{"code":"0352","type":"RC"},{"code":"71250","type":"HCPCS"}],"standard_charges":[{"gross_charge":1517.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORAX W CONTRAST MATERIAL","code_information":[{"code":"3500000015","type":"CDM"},{"code":"0352","type":"RC"},{"code":"71260","type":"HCPCS"}],"standard_charges":[{"gross_charge":1804.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORAX W WO CONTRAST MATERIAL","code_information":[{"code":"3500000016","type":"CDM"},{"code":"0352","type":"RC"},{"code":"71270","type":"HCPCS"}],"standard_charges":[{"gross_charge":2778.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY CHEST W WO CONTRAST","code_information":[{"code":"3500000017","type":"CDM"},{"code":"0352","type":"RC"},{"code":"71275","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT CERVICAL SPINE WO CONTRAST MATERIAL","code_information":[{"code":"3500000018","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72125","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT CERVICAL SPINE W CONTRAST MATERIAL","code_information":[{"code":"3500000019","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72126","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT CERVICAL SPINE W WO CONTRAST MATERIAL","code_information":[{"code":"3500000020","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72127","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORACIC SPINE WO CONTRAST MATERIAL","code_information":[{"code":"3500000021","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72128","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORACIC SPINE W CONTRAST MATERIAL","code_information":[{"code":"3500000022","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72129","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORACIC SPINE W WO CONTRAST MATERIAL","code_information":[{"code":"3500000023","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72130","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LUMBAR SPINE WO CONTRAST MATERIAL","code_information":[{"code":"3500000024","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72131","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LUMBAR SPINE W CONTRAST MATERIAL","code_information":[{"code":"3500000025","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72132","type":"HCPCS"}],"standard_charges":[{"gross_charge":2769.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LUMBAR SPINE W WO CONTRAST MATERIAL","code_information":[{"code":"3500000026","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72133","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY PELVIS W WO CONTRAST","code_information":[{"code":"3500000027","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72191","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT PELVIS WO CONTRAST MATERIAL","code_information":[{"code":"3500000028","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72192","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT PELVIS W CONTRAST MATERIAL","code_information":[{"code":"3500000029","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72193","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT PELVIS W WO CONTRAST MATERIAL","code_information":[{"code":"3500000030","type":"CDM"},{"code":"0352","type":"RC"},{"code":"72194","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT UPPER EXTREMITY WO CONTRAST MATERIAL","code_information":[{"code":"3500000031","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73200","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT UPPER EXTREMITY W CONTRAST MATERIAL","code_information":[{"code":"3500000032","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73201","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT UPPER EXTREMITY W WO CONTRAST MATERIAL","code_information":[{"code":"3500000033","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73202","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY UPPER EXTR","code_information":[{"code":"3500000034","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73206","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LOWER EXTREMITY WO CONTRAST MATERIAL","code_information":[{"code":"3500000035","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73700","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LOWER EXTREMITY W CONTRAST MATERIAL","code_information":[{"code":"3500000036","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73701","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LOWER EXTREMITY W WO CONTRAST MATERIAL","code_information":[{"code":"3500000037","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73702","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY LOWER EXTR","code_information":[{"code":"3500000038","type":"CDM"},{"code":"0352","type":"RC"},{"code":"73706","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ABD WO CONTRAST MATERIAL","code_information":[{"code":"3500000039","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74150","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ABD W CONTRAST MATERIAL","code_information":[{"code":"3500000040","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74160","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ABD W WO CONTRAST MATERIAL","code_information":[{"code":"3500000041","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74170","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOFRAPHY ABD PELVIS CONTRAST MTRL W WO CONTRAST IMG","code_information":[{"code":"3500000042","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74174","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ANGIOGRAPHY ABD W WO CONTRAST","code_information":[{"code":"3500000043","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74175","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ABD AND PELVIS WO CONTRAST MATERIAL","code_information":[{"code":"3500000044","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74176","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ABD AND PELVIS W CONTRAST MATERIAL","code_information":[{"code":"3500000045","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74177","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT ABD AND PELVIS W/& WO CONTRAST 1 OR MORE BODY REGIONS","code_information":[{"code":"3500000046","type":"CDM"},{"code":"0352","type":"RC"},{"code":"74178","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT COLONOGRAPHY DIAG IMAGE POSTPROCESS WO CONTRAST","code_information":[{"code":"3500000047","type":"CDM"},{"code":"0350","type":"RC"},{"code":"74261","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING","code_information":[{"code":"3500000048","type":"CDM"},{"code":"0350","type":"RC"},{"code":"74263","type":"HCPCS"}],"standard_charges":[{"gross_charge":2174.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT HEART W O CONTRAST QUANT EVAL CORONARY CALCIUM","code_information":[{"code":"3500000049","type":"CDM"},{"code":"0350","type":"RC"},{"code":"75571","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT HEART CONTRAST EVAL CARDIAC STRUCTURE AND MORPH","code_information":[{"code":"3500000050","type":"CDM"},{"code":"0350","type":"RC"},{"code":"75572","type":"HCPCS"}],"standard_charges":[{"gross_charge":1108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CTA HEART CORONARY ART BYPASS GRAFTS CONTRAST 3D IMAGE","code_information":[{"code":"3500000051","type":"CDM"},{"code":"0350","type":"RC"},{"code":"75574","type":"HCPCS"}],"standard_charges":[{"gross_charge":1108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CTA ABDOMINAL AORTA AND BI ILIOFEM W CONTRAST AND POST","code_information":[{"code":"3500000052","type":"CDM"},{"code":"0352","type":"RC"},{"code":"75635","type":"HCPCS"}],"standard_charges":[{"gross_charge":1499.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT LIMITED OR LOCALIZED FOLLOW UP STUDY","code_information":[{"code":"3500000053","type":"CDM"},{"code":"0350","type":"RC"},{"code":"76380","type":"HCPCS"}],"standard_charges":[{"gross_charge":789.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT GUIDANCE STEROTACTIC LOCAL","code_information":[{"code":"3500000054","type":"CDM"},{"code":"0350","type":"RC"},{"code":"77011","type":"HCPCS"}],"standard_charges":[{"gross_charge":1901.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT GUIDANCE NEEDLE PLACEMENT","code_information":[{"code":"3500000055","type":"CDM"},{"code":"0350","type":"RC"},{"code":"77012","type":"HCPCS"}],"standard_charges":[{"gross_charge":2458.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT GUIDANCE AND MONITORING VISC TISSUE ABLATION","code_information":[{"code":"3500000056","type":"CDM"},{"code":"0350","type":"RC"},{"code":"77013","type":"HCPCS"}],"standard_charges":[{"gross_charge":2638.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT","code_information":[{"code":"3500000057","type":"CDM"},{"code":"0350","type":"RC"},{"code":"77014","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT CEREBRAL PERFUSION ANALYSIS W BLOOD FLOW AND VOL","code_information":[{"code":"3500000058","type":"CDM"},{"code":"0350","type":"RC"},{"code":"0042T","type":"HCPCS"}],"standard_charges":[{"gross_charge":1377.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 3D CT RENDERING W INTER AND POSTPROCESS SUPERVISION","code_information":[{"code":"3500000063","type":"CDM"},{"code":"0350","type":"RC"},{"code":"76376","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHG CALCIUM SCORING SELF-PAY EXAM","code_information":[{"code":"3500000072","type":"CDM"},{"code":"0350","type":"RC"},{"code":"75571","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"setting":"both","modifiers":"SPE","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard | The modified price is presented in the standard charge value. | Modifier SPE: Modifier description not available"}]},{"description":"HC 3D ANAT SEG IMAGING PREOP","code_information":[{"code":"3500000073","type":"CDM"},{"code":"0350","type":"RC"},{"code":"C8001","type":"HCPCS"}],"standard_charges":[{"gross_charge":485.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SOFTWARE MEAS OF CARDIAC VOL","code_information":[{"code":"3500000074","type":"CDM"},{"code":"0350","type":"RC"},{"code":"G0183","type":"HCPCS"}],"standard_charges":[{"gross_charge":273.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CT THORAX LOW DOSE LUNG CANCER SCREENING C-","code_information":[{"code":"3520000001","type":"CDM"},{"code":"0352","type":"RC"},{"code":"71271","type":"HCPCS"}],"standard_charges":[{"gross_charge":997.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CERCLAGE OF CERVIX DURING PREGNANCY VAG APPROACH","code_information":[{"code":"3600000001","type":"CDM"},{"code":"0761","type":"RC"},{"code":"59320","type":"HCPCS"}],"standard_charges":[{"gross_charge":3774.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 1 INITIAL 15 MIN","code_information":[{"code":"3600000003","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000003","type":"HCPCS"}],"standard_charges":[{"gross_charge":1744.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 2 INITIAL 15 MIN","code_information":[{"code":"3600000004","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000004","type":"HCPCS"}],"standard_charges":[{"gross_charge":2016.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 3 INITIAL 15 MIN","code_information":[{"code":"3600000005","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000005","type":"HCPCS"}],"standard_charges":[{"gross_charge":2287.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 4 INITIAL 15 MIN","code_information":[{"code":"3600000006","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000006","type":"HCPCS"}],"standard_charges":[{"gross_charge":2559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 1 ADDL 15 MIN","code_information":[{"code":"3600000007","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000007","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 2 ADDL 15 MIN","code_information":[{"code":"3600000008","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000008","type":"HCPCS"}],"standard_charges":[{"gross_charge":548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 3 ADDL 15 MIN","code_information":[{"code":"3600000009","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000009","type":"HCPCS"}],"standard_charges":[{"gross_charge":821.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 4 ADDL 15 MIN","code_information":[{"code":"3600000010","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000010","type":"HCPCS"}],"standard_charges":[{"gross_charge":1094.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE UTERUS AFTER CESAREAN","code_information":[{"code":"3600000015","type":"CDM"},{"code":"0360","type":"RC"},{"code":"59525","type":"HCPCS"}],"standard_charges":[{"gross_charge":8821.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OB SURGERY LEVEL 1 - 1ST 15 MINS","code_information":[{"code":"3600000020","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000020","type":"HCPCS"}],"standard_charges":[{"gross_charge":555.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OB SURGERY LEVEL 1 - EA ADD 15 MINS","code_information":[{"code":"3600000021","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000021","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OB SURGERY LEVEL 2 - 1ST 15 MINS","code_information":[{"code":"3600000022","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000022","type":"HCPCS"}],"standard_charges":[{"gross_charge":631.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OB SURGERY LEVEL 2 - EA ADD 15 MINS","code_information":[{"code":"3600000023","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000023","type":"HCPCS"}],"standard_charges":[{"gross_charge":421.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 1 - 1ST 15 MIN","code_information":[{"code":"3600000024","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000024","type":"HCPCS"}],"standard_charges":[{"gross_charge":1825.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 1 - EA ADD 15 MIN","code_information":[{"code":"3600000025","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000025","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 2 - 1ST 15 MIN","code_information":[{"code":"3600000026","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000026","type":"HCPCS"}],"standard_charges":[{"gross_charge":1895.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 2 - EA ADD 15 MINS","code_information":[{"code":"3600000027","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000027","type":"HCPCS"}],"standard_charges":[{"gross_charge":631.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 3 - 1ST 15 MIN","code_information":[{"code":"3600000028","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000028","type":"HCPCS"}],"standard_charges":[{"gross_charge":2186.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 3 - EA ADD 15 MIN","code_information":[{"code":"3600000029","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000029","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 4 - 1ST 15 MIN","code_information":[{"code":"3600000030","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000030","type":"HCPCS"}],"standard_charges":[{"gross_charge":2340.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 4 - EA ADD 15 MIN","code_information":[{"code":"3600000031","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000031","type":"HCPCS"}],"standard_charges":[{"gross_charge":780.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 5 - 1ST 15 MIN","code_information":[{"code":"3600000032","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000032","type":"HCPCS"}],"standard_charges":[{"gross_charge":2456.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SURGERY LEVEL 5 - EA ADD 15 MIN","code_information":[{"code":"3600000033","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3600000033","type":"HCPCS"}],"standard_charges":[{"gross_charge":819.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX","code_information":[{"code":"3600000035","type":"CDM"},{"code":"0360","type":"RC"},{"code":"27006","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN","code_information":[{"code":"3600000036","type":"CDM"},{"code":"0360","type":"RC"},{"code":"23000","type":"HCPCS"}],"standard_charges":[{"gross_charge":8586.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY SHOULDER AREA 1 TENDON","code_information":[{"code":"3600000037","type":"CDM"},{"code":"0360","type":"RC"},{"code":"23405","type":"HCPCS"}],"standard_charges":[{"gross_charge":21431.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION","code_information":[{"code":"3600000038","type":"CDM"},{"code":"0360","type":"RC"},{"code":"23406","type":"HCPCS"}],"standard_charges":[{"gross_charge":21431.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN","code_information":[{"code":"3600000039","type":"CDM"},{"code":"0360","type":"RC"},{"code":"24358","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR","code_information":[{"code":"3600000040","type":"CDM"},{"code":"0360","type":"RC"},{"code":"24359","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY ADDUCTOR HIP OPEN","code_information":[{"code":"3600000041","type":"CDM"},{"code":"0360","type":"RC"},{"code":"27001","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX","code_information":[{"code":"3600000042","type":"CDM"},{"code":"0360","type":"RC"},{"code":"27306","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON","code_information":[{"code":"3600000043","type":"CDM"},{"code":"0360","type":"RC"},{"code":"27307","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES","code_information":[{"code":"3600000044","type":"CDM"},{"code":"0360","type":"RC"},{"code":"27605","type":"HCPCS"}],"standard_charges":[{"gross_charge":4801.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES","code_information":[{"code":"3600000045","type":"CDM"},{"code":"0360","type":"RC"},{"code":"27606","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FASCIECTOMY PLANTAR FASCIA PARTIAL SPX","code_information":[{"code":"3600000046","type":"CDM"},{"code":"0360","type":"RC"},{"code":"28060","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FASCIECTOMY PLANTAR FASCIA RADICAL SPX","code_information":[{"code":"3600000047","type":"CDM"},{"code":"0360","type":"RC"},{"code":"28062","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 1 INITIAL 15 MIN COSMETIC","code_information":[{"code":"3601444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3601444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":1744.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 1 ADDL 15 MIN COSMETIC","code_information":[{"code":"3602444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3602444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 2 INITIAL 15 MIN COSMETIC","code_information":[{"code":"3603444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3603444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":2016.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 2 ADDL 15 MIN COSMETIC","code_information":[{"code":"3605444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3605444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 3 INITIAL 15 MIN COSMETIC","code_information":[{"code":"3606444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3606444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":2287.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 3 ADDL 15 MIN COSMETIC","code_information":[{"code":"3607444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3607444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":821.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 4 INITIAL 15 MIN COSMETIC","code_information":[{"code":"3608444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3608444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":2559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TEAM TIME LEVEL 4 ADDL 15 MIN COSMETIC","code_information":[{"code":"3609444444","type":"CDM"},{"code":"0360","type":"RC"},{"code":"3609444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":1094.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIGATION TRNSX FALOP TUBE CESAREAN DEL ABD SURG","code_information":[{"code":"3610000000","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58611","type":"HCPCS"}],"standard_charges":[{"gross_charge":4565.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TAP BLOCK UNI BY INJECTIONS W/IMG GDN","code_information":[{"code":"3610000001","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64486","type":"HCPCS"}],"standard_charges":[{"gross_charge":1788.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIGATION TRNSX FALOP TUBE ABD VAG POSTP SEP PROC  UNI OR BI","code_information":[{"code":"3610000003","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58605","type":"HCPCS"}],"standard_charges":[{"gross_charge":6949.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TAP BLOCK BILAT BY CONTINUOUS INFUSIONS W/IMG GDN","code_information":[{"code":"3610000004","type":"CDM"},{"code":"0361","type":"RC"},{"code":"64489","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TAP BLOCK UNI BY CONT INFUSIONS W/IMG GDN","code_information":[{"code":"3610000005","type":"CDM"},{"code":"0361","type":"RC"},{"code":"64487","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TAP BLOCK BILAT BY INJECTIONS W/IMG GDN","code_information":[{"code":"3610000006","type":"CDM"},{"code":"0361","type":"RC"},{"code":"64488","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IVUS NON CORONARY DURING DIAG EVAL AND/OR THER INTERVENTION INIT","code_information":[{"code":"3610000008","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37252","type":"HCPCS"}],"standard_charges":[{"gross_charge":589.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IVUS NON CORONARY DURING DIAG EVAL AND/OR THER INTERVENTION EA ADDL","code_information":[{"code":"3610000009","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37253","type":"HCPCS"}],"standard_charges":[{"gross_charge":221.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ CONTRST KNEE ARTHOGRAPHY OR CNTRST ENHNCD CT MRI KNEE","code_information":[{"code":"3610000020","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27369","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH REMOVAL PERM LEADLESS PACEMAKER R VENTRICAL","code_information":[{"code":"3610000021","type":"CDM"},{"code":"0361","type":"RC"},{"code":"33275","type":"HCPCS"}],"standard_charges":[{"gross_charge":9698.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH INST RPL PERM LEADLESS PACEMAKER RV, INCL IMG","code_information":[{"code":"3610000022","type":"CDM"},{"code":"0510","type":"RC"},{"code":"33274","type":"HCPCS"}],"standard_charges":[{"gross_charge":56372.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERTION SUBQ CARDIAC RHYTHM MONITOR W PRGRMG","code_information":[{"code":"3610000023","type":"CDM"},{"code":"0361","type":"RC"},{"code":"33285","type":"HCPCS"}],"standard_charges":[{"gross_charge":27185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR","code_information":[{"code":"3610000024","type":"CDM"},{"code":"0361","type":"RC"},{"code":"33286","type":"HCPCS"}],"standard_charges":[{"gross_charge":2130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESW INTEGUMENTARY WOUND HEALING INITIAL WOUND","code_information":[{"code":"3610000027","type":"CDM"},{"code":"0361","type":"RC"},{"code":"0512T","type":"HCPCS"}],"standard_charges":[{"gross_charge":853.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUSCLE MYOCUTANEOUS FASCIOCUTANEOUS FLAP UPPER EXTREMITY","code_information":[{"code":"3610000028","type":"CDM"},{"code":"0361","type":"RC"},{"code":"15736","type":"HCPCS"}],"standard_charges":[{"gross_charge":6745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THERMAL DSTRJ INTRAOSSEOUS BVN 1ST 2 LMBR/SAC","code_information":[{"code":"3610000037","type":"CDM"},{"code":"0361","type":"RC"},{"code":"64628","type":"HCPCS"}],"standard_charges":[{"gross_charge":17908.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THERMAL DSTRJ INTRAOSSEOUS BVN EA ADDL LMBR/SAC","code_information":[{"code":"3610000038","type":"CDM"},{"code":"0361","type":"RC"},{"code":"64629","type":"HCPCS"}],"standard_charges":[{"gross_charge":6050.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROBOTIC SURGICAL SYSTEM","code_information":[{"code":"3610000039","type":"CDM"},{"code":"0361","type":"RC"},{"code":"S2900","type":"HCPCS"}],"standard_charges":[{"gross_charge":0.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRNSCTH RENAL SYMP DENRV UNL","code_information":[{"code":"3610000048","type":"CDM"},{"code":"0361","type":"RC"},{"code":"0338T","type":"HCPCS"}],"standard_charges":[{"gross_charge":17704.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRNSCTH RENAL SYMP DENRV BIL","code_information":[{"code":"3610000049","type":"CDM"},{"code":"0361","type":"RC"},{"code":"0339T","type":"HCPCS"}],"standard_charges":[{"gross_charge":17704.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PEF BRONCH ABLT 3D NAV EBUS","code_information":[{"code":"3610000056","type":"CDM"},{"code":"0361","type":"RC"},{"code":"C8005","type":"HCPCS"}],"standard_charges":[{"gross_charge":13105.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABLTJ PERC CRYOABLTJ IMG GDN LXTR/PERPH NERVE","code_information":[{"code":"3610000058","type":"CDM"},{"code":"0361","type":"RC"},{"code":"0441T","type":"HCPCS"}],"standard_charges":[{"gross_charge":12148.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UNLISTED PROCEDURE FEMUR/KNEE","code_information":[{"code":"3610000059","type":"CDM"},{"code":"0361","type":"RC"},{"code":"27599","type":"HCPCS"}],"standard_charges":[{"gross_charge":720.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UNLISTED PROCEDURE CARDIAC SURGERY","code_information":[{"code":"3610000061","type":"CDM"},{"code":"0361","type":"RC"},{"code":"33999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1227.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ALLOGENEIC LYMPHOCYTE INFUSIONS","code_information":[{"code":"3620000000","type":"CDM"},{"code":"0362","type":"RC"},{"code":"38242","type":"HCPCS"}],"standard_charges":[{"gross_charge":9495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANESTHESIA","code_information":[{"code":"3700000000","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3700000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SEVOFLURANE 250ML","code_information":[{"code":"3700000005","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3700000005","type":"HCPCS"}],"standard_charges":[{"gross_charge":473.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EPIDURAL ANESTHESIA","code_information":[{"code":"3700000007","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3700000007","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSTETRIC PROCEDURE ANESTHESIA","code_information":[{"code":"3700000008","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3700000008","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED SAME PHYS QHP INITIAL 15MIN 5 >YRS","code_information":[{"code":"3700000009","type":"CDM"},{"code":"0370","type":"RC"},{"code":"G0500","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANESTHESIA - 1ST 15 MINS","code_information":[{"code":"3700000010","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3700000010","type":"HCPCS"}],"standard_charges":[{"gross_charge":232.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANESTHESIA - EACH ADD 15 MINS","code_information":[{"code":"3700000011","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3700000011","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANESTHESIA COSMETIC","code_information":[{"code":"3704444444","type":"CDM"},{"code":"0370","type":"RC"},{"code":"3704444444","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED SAME PHYS QHP INITIAL 15 MINS LESS THAN5 YRS","code_information":[{"code":"3710000002","type":"CDM"},{"code":"0370","type":"RC"},{"code":"99151","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED SAME PHYS QHP INITIAL 15 MINS 5 GREATER THAN YRS","code_information":[{"code":"3710000003","type":"CDM"},{"code":"0370","type":"RC"},{"code":"99152","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED SAME PHYS QHP EACH ADDL 15 MINS","code_information":[{"code":"3710000004","type":"CDM"},{"code":"0370","type":"RC"},{"code":"99153","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED OTHER PHYS QHP INITIAL 15 MINS LESS THAN5 YRS","code_information":[{"code":"3710000005","type":"CDM"},{"code":"0370","type":"RC"},{"code":"99155","type":"HCPCS"}],"standard_charges":[{"gross_charge":292.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED OTHER PHYS QHP INITIAL 15 MINS 5 GREATER THAN YRS","code_information":[{"code":"3710000006","type":"CDM"},{"code":"0370","type":"RC"},{"code":"99156","type":"HCPCS"}],"standard_charges":[{"gross_charge":237.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOD SED OTHER PHYS QHP EACH ADDL 15 MINS","code_information":[{"code":"3710000007","type":"CDM"},{"code":"0370","type":"RC"},{"code":"99157","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AUTOLOGOUS WHOLE BLOOD","code_information":[{"code":"3900000003","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9010","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRYOPRECIPITATE","code_information":[{"code":"3900000004","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9012","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RED BLOOD CELLS LEUKO RED","code_information":[{"code":"3900000005","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9016","type":"HCPCS"}],"standard_charges":[{"gross_charge":505.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RED BLOOD CELLS WASHED","code_information":[{"code":"3900000006","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9022","type":"HCPCS"}],"standard_charges":[{"gross_charge":789.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS PHER LEUKO RED","code_information":[{"code":"3900000007","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9035","type":"HCPCS"}],"standard_charges":[{"gross_charge":1715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS PHER LEUKO RED IRRAD","code_information":[{"code":"3900000008","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9037","type":"HCPCS"}],"standard_charges":[{"gross_charge":1715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RED BLOOD CELLS LEUK RED IRRAD","code_information":[{"code":"3900000009","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9040","type":"HCPCS"}],"standard_charges":[{"gross_charge":1028.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS PHER LEUKO RED HLA MCH","code_information":[{"code":"3900000010","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9052","type":"HCPCS"}],"standard_charges":[{"gross_charge":945.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLASMA FROZEN IN 24-HR PERIOD","code_information":[{"code":"3900000011","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9059","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXCHANGE WHOLE BLOOD UNIT","code_information":[{"code":"3900000012","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9017","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIRECTED DONOR PLATELETS","code_information":[{"code":"3900000013","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9019","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RED BLOOD CELLS","code_information":[{"code":"3900000014","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9021","type":"HCPCS"}],"standard_charges":[{"gross_charge":448.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RED BLOOD CELLS IRRADIATED EACH UNIT","code_information":[{"code":"3900000015","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9038","type":"HCPCS"}],"standard_charges":[{"gross_charge":675.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RED BLOOD CELLS DEGLYCEROLIZED","code_information":[{"code":"3900000016","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9039","type":"HCPCS"}],"standard_charges":[{"gross_charge":1303.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS LEUKOCYTES REDUCED","code_information":[{"code":"3900000020","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9031","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS LEUKOREDUCED IRRAD","code_information":[{"code":"3900000022","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9033","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS, PHERESIS","code_information":[{"code":"3900000023","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9034","type":"HCPCS"}],"standard_charges":[{"gross_charge":887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELETS PHERESIS PATH REDUCED EA UNIT","code_information":[{"code":"3900000027","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9073","type":"HCPCS"}],"standard_charges":[{"gross_charge":792.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLATELET BLOOD PRODUCT","code_information":[{"code":"3900000035","type":"CDM"},{"code":"0390","type":"RC"},{"code":"P9019","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSFUSION BLOOD OR BLOOD COMPONENTS","code_information":[{"code":"3910000000","type":"CDM"},{"code":"0391","type":"RC"},{"code":"36430","type":"HCPCS"}],"standard_charges":[{"gross_charge":877.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BREAST TOMOSYNTHESIS","code_information":[{"code":"4000000000","type":"CDM"},{"code":"0320","type":"RC"},{"code":"76499","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIGITAL BREAST TOMOSYNTHESIS UNI","code_information":[{"code":"4010000005","type":"CDM"},{"code":"0401","type":"RC"},{"code":"77061","type":"HCPCS"}],"standard_charges":[{"gross_charge":487.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIGITAL BREAST TOMOSYNTHESIS BILATERAL","code_information":[{"code":"4010000006","type":"CDM"},{"code":"0401","type":"RC"},{"code":"77062","type":"HCPCS"}],"standard_charges":[{"gross_charge":487.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETCJ UNI","code_information":[{"code":"4010000007","type":"CDM"},{"code":"0401","type":"RC"},{"code":"G0206","type":"HCPCS"}],"standard_charges":[{"gross_charge":504.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETCJ BI","code_information":[{"code":"4010000008","type":"CDM"},{"code":"0401","type":"RC"},{"code":"G0204","type":"HCPCS"}],"standard_charges":[{"gross_charge":585.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETCJ BI","code_information":[{"code":"4010000009","type":"CDM"},{"code":"0401","type":"RC"},{"code":"77066","type":"HCPCS"}],"standard_charges":[{"gross_charge":748.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETCJ UNI","code_information":[{"code":"4010000010","type":"CDM"},{"code":"0401","type":"RC"},{"code":"77065","type":"HCPCS"}],"standard_charges":[{"gross_charge":445.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHOENCEPHALOGRAPHY REAL TIME IMAGE","code_information":[{"code":"4020000000","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76506","type":"HCPCS"}],"standard_charges":[{"gross_charge":646.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPHTHALMIC US DIAG B SCAN W WO A SCAN","code_information":[{"code":"4020000003","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76512","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPHTHALMIC US DIAG CORNEAL PACHYMETRY UNILAT BILAT","code_information":[{"code":"4020000005","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76514","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US SOFT TISSUE HEAD AND NECK REAL TIME IMAGE DOC","code_information":[{"code":"4020000007","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76536","type":"HCPCS"}],"standard_charges":[{"gross_charge":759.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US CHEST REAL TIME W IMAGE DOCUMENTATION","code_information":[{"code":"4020000008","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76604","type":"HCPCS"}],"standard_charges":[{"gross_charge":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US ABDOMINAL REAL TIME W IMAGE DOCUMENTATION","code_information":[{"code":"4020000010","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1214.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US ABDOMINAL REAL TIME W IMAGE LTD","code_information":[{"code":"4020000011","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76705","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US RETROPERITONEAL REAL TIME W IMAGE COMPL","code_information":[{"code":"4020000012","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76770","type":"HCPCS"}],"standard_charges":[{"gross_charge":693.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US RETROPERITONEAL REAL TIME W IMAGE LTD","code_information":[{"code":"4020000013","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76775","type":"HCPCS"}],"standard_charges":[{"gross_charge":408.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US SPINAL CANAL AND CONTENTS","code_information":[{"code":"4020000015","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76800","type":"HCPCS"}],"standard_charges":[{"gross_charge":681.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS 14 WK TRANSABD 1 1ST GESTATION","code_information":[{"code":"4020000016","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76801","type":"HCPCS"}],"standard_charges":[{"gross_charge":951.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS 14 WK TRANSABD EA ADDL GESTATION","code_information":[{"code":"4020000017","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76802","type":"HCPCS"}],"standard_charges":[{"gross_charge":896.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS AFTER 1ST TRIMEST 1 1ST GESTATION","code_information":[{"code":"4020000018","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76805","type":"HCPCS"}],"standard_charges":[{"gross_charge":987.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS AFTER 1ST TRIMEST ABD EA GESTATION","code_information":[{"code":"4020000019","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76810","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS W DETAIL FETAL ANAT 1ST GESTATION","code_information":[{"code":"4020000020","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76811","type":"HCPCS"}],"standard_charges":[{"gross_charge":900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS DETAIL FETAL ANAT EXAM EA ADDL GESTATION","code_information":[{"code":"4020000021","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76812","type":"HCPCS"}],"standard_charges":[{"gross_charge":445.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION","code_information":[{"code":"4020000022","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76813","type":"HCPCS"}],"standard_charges":[{"gross_charge":882.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION","code_information":[{"code":"4020000023","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76814","type":"HCPCS"}],"standard_charges":[{"gross_charge":973.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS LTD 1 OR MORE FETUSES","code_information":[{"code":"4020000024","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76815","type":"HCPCS"}],"standard_charges":[{"gross_charge":635.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS REAL TIME FU TRANSABD PER FETUS","code_information":[{"code":"4020000025","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76816","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PREG UTERUS REAL TIME W IMAGE DCMTN TRANSVAG","code_information":[{"code":"4020000026","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76817","type":"HCPCS"}],"standard_charges":[{"gross_charge":759.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US FETAL BIOPHYSICAL PROFILE WO NON-STRESS TESTING","code_information":[{"code":"4020000027","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76819","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US DOPPLER VELOCIMETRY FETAL UMBILICAL ARTERY","code_information":[{"code":"4020000028","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76820","type":"HCPCS"}],"standard_charges":[{"gross_charge":613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US TRANSVAGINAL","code_information":[{"code":"4020000029","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76830","type":"HCPCS"}],"standard_charges":[{"gross_charge":759.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SALINE INFUS SONOHYSTEROGRAPHY W COLOR DOPPLER","code_information":[{"code":"4020000030","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76831","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PELVIC NON OBSTETRIC REAL TIME IMAGE COMPL","code_information":[{"code":"4020000031","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76856","type":"HCPCS"}],"standard_charges":[{"gross_charge":985.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US PELVIC NON OBSTETRIC IMAGE DCMTN LTD FU","code_information":[{"code":"4020000032","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76857","type":"HCPCS"}],"standard_charges":[{"gross_charge":1005.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US SCROTUM AND CONTENTS","code_information":[{"code":"4020000033","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76870","type":"HCPCS"}],"standard_charges":[{"gross_charge":911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US TRANSRECTAL","code_information":[{"code":"4020000034","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76872","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US TRANSRCT PRSTATE VOL BRACHYTX PLANNING SEP PROC","code_information":[{"code":"4020000035","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76873","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US EXTMVLITY NON VASC REAL TIME IMAGE COMPL","code_information":[{"code":"4020000036","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76881","type":"HCPCS"}],"standard_charges":[{"gross_charge":625.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US EXTMVLITY NON VASC REAL TIME IMAGE LTD","code_information":[{"code":"4020000037","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76882","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US INFT HIPS R T IMAGE DYNAMIC REQ PHYS QHP MANIP","code_information":[{"code":"4020000038","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76885","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US INFT HIPS R T IMAGE LTD STATIC PHYS QHP MANIP","code_information":[{"code":"4020000039","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76886","type":"HCPCS"}],"standard_charges":[{"gross_charge":2709.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US COMPRN REPAIR ARTL PSEUDOARYSM ARVEN FSTL","code_information":[{"code":"4020000042","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76936","type":"HCPCS"}],"standard_charges":[{"gross_charge":899.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US VASC ACCESS SITS VSL PATENCY NEEDLE ENTRY","code_information":[{"code":"4020000043","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76937","type":"HCPCS"}],"standard_charges":[{"gross_charge":401.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US AND MONITOR PARENCHYMAL TISSUE ABLATION","code_information":[{"code":"4020000044","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76940","type":"HCPCS"}],"standard_charges":[{"gross_charge":2551.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US GUIDANCE NEEDLE PLACEMENT","code_information":[{"code":"4020000045","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76942","type":"HCPCS"}],"standard_charges":[{"gross_charge":659.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US GUIDANCE AMNIOCENTESIS","code_information":[{"code":"4020000046","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76946","type":"HCPCS"}],"standard_charges":[{"gross_charge":1010.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US GUIDANCE INTRAOPERATIVE","code_information":[{"code":"4020000048","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76998","type":"HCPCS"}],"standard_charges":[{"gross_charge":347.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US GUIDANCE INTERSTITIAL RADIOELMENT APPLICATION","code_information":[{"code":"4020000050","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76965","type":"HCPCS"}],"standard_charges":[{"gross_charge":882.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US BREAST UNI REAL TIME W IMAGE LIM","code_information":[{"code":"4020000052","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76642","type":"HCPCS"}],"standard_charges":[{"gross_charge":319.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US BREAST UNI REAL TIME W IMAGE COMP","code_information":[{"code":"4020000053","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76641","type":"HCPCS"}],"standard_charges":[{"gross_charge":413.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FETAL DOPPLER MIDDLE CEREBRAL ARTERY","code_information":[{"code":"4020000055","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76821","type":"HCPCS"}],"standard_charges":[{"gross_charge":613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIVER ELASTOGRAPHY","code_information":[{"code":"4020000056","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91200","type":"HCPCS"}],"standard_charges":[{"gross_charge":512.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA","code_information":[{"code":"4020000058","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76706","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GREY SCALE ULTRASOUND","code_information":[{"code":"4020000060","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76999","type":"HCPCS"}],"standard_charges":[{"gross_charge":306.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION","code_information":[{"code":"4020000062","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76978","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ULTRASOUND ELASTOGRAPHY PARENCHYMA","code_information":[{"code":"4020000064","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76981","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ULTRASOUND ELASTOGRAPHY FIRST TARGET LESION","code_information":[{"code":"4020000065","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76982","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FETAL BIOPHYSICAL PROFILE","code_information":[{"code":"4020000067","type":"CDM"},{"code":"0402","type":"RC"},{"code":"76818","type":"HCPCS"}],"standard_charges":[{"gross_charge":416.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SCREENING DIGITAL BREAST TOMOSYNTHESIS BI","code_information":[{"code":"4030000002","type":"CDM"},{"code":"0403","type":"RC"},{"code":"77063","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SCREENING MAMMOGRAPHY BI 2 VIEW BREAST INC CAD","code_information":[{"code":"4030000003","type":"CDM"},{"code":"0403","type":"RC"},{"code":"G0202","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SCREENING MAMMOGRAPHY BI 2 VIEW BREAST INC CAD","code_information":[{"code":"4030000004","type":"CDM"},{"code":"0403","type":"RC"},{"code":"77067","type":"HCPCS"}],"standard_charges":[{"gross_charge":598.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRAIN IMAGE PET METABOLIC EVAL","code_information":[{"code":"4040000001","type":"CDM"},{"code":"0404","type":"RC"},{"code":"78608","type":"HCPCS"}],"standard_charges":[{"gross_charge":3863.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PET IMAGE CT FOR ATTENUATION LTD AREA","code_information":[{"code":"4040000002","type":"CDM"},{"code":"0404","type":"RC"},{"code":"78814","type":"HCPCS"}],"standard_charges":[{"gross_charge":6620.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PET IMAGE CT ATTENUATION SKULL BASE MID THIGH","code_information":[{"code":"4040000003","type":"CDM"},{"code":"0404","type":"RC"},{"code":"78815","type":"HCPCS"}],"standard_charges":[{"gross_charge":8657.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PET IMAGE CT ATTENUATION WHOLE BODY","code_information":[{"code":"4040000004","type":"CDM"},{"code":"0404","type":"RC"},{"code":"78816","type":"HCPCS"}],"standard_charges":[{"gross_charge":11076.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PET IMAGING LIMITED AREA CHEST HEAD/NECK","code_information":[{"code":"4040000009","type":"CDM"},{"code":"0404","type":"RC"},{"code":"78811","type":"HCPCS"}],"standard_charges":[{"gross_charge":3602.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOCRD IMG PET METAB EVAL SINGLE STUDY CNCRNT CT","code_information":[{"code":"4040000010","type":"CDM"},{"code":"0404","type":"RC"},{"code":"78429","type":"HCPCS"}],"standard_charges":[{"gross_charge":4393.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENTILATION ASSIST AND MGMT IP 1ST DAY","code_information":[{"code":"4100000001","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94002","type":"HCPCS"}],"standard_charges":[{"gross_charge":1088.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENTILATION ASSIST AND MGMT IP EA SUBS DAY","code_information":[{"code":"4100000002","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94003","type":"HCPCS"}],"standard_charges":[{"gross_charge":1220.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRESSURIZED NON-PRESSURIZED INHALATION TRTMT","code_information":[{"code":"4100000003","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94640","type":"HCPCS"}],"standard_charges":[{"gross_charge":325.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS PROPH","code_information":[{"code":"4100000004","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94642","type":"HCPCS"}],"standard_charges":[{"gross_charge":672.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONTINUOUS INHALATION TRTMT 1ST HR","code_information":[{"code":"4100000005","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94644","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CPAP VENTILATION CPAP INITIATION AND MGMT","code_information":[{"code":"4100000006","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94660","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MANIP CHEST WALL FACILITATE LUNG FUNC 1 DEMO AND EVAL","code_information":[{"code":"4100000007","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94667","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MANIP CHEST WALL FACILITATE LUNG FUNC SUBS","code_information":[{"code":"4100000008","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94668","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INHAL BRNCL CHALLENGE TESTG W HISTAM METHACHOL","code_information":[{"code":"4100000010","type":"CDM"},{"code":"0924","type":"RC"},{"code":"95070","type":"HCPCS"}],"standard_charges":[{"gross_charge":1713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INDIVIDUAL RESPIRATORY THERAPY EXERCISE(S) EACH 15 MIN","code_information":[{"code":"4100000012","type":"CDM"},{"code":"0410","type":"RC"},{"code":"G0237","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GROUP RESPIRATORY THERAPY EXERCISE(S)","code_information":[{"code":"4100000013","type":"CDM"},{"code":"0410","type":"RC"},{"code":"G0239","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONTINUOUS INHALATION TRTMT EA ADDL HR","code_information":[{"code":"4100000014","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94645","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CNSL VISIT DISCUSS LDCT USING LOW DOSE CT SCAN","code_information":[{"code":"4100000016","type":"CDM"},{"code":"0410","type":"RC"},{"code":"G0296","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HBO FULL BODY PER 30MIN","code_information":[{"code":"4130000000","type":"CDM"},{"code":"0413","type":"RC"},{"code":"G0277","type":"HCPCS"}],"standard_charges":[{"gross_charge":490.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING SHOULDER","code_information":[{"code":"4200000000","type":"CDM"},{"code":"0700","type":"RC"},{"code":"29240","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING ELBOW OR WRIST","code_information":[{"code":"4200000001","type":"CDM"},{"code":"0700","type":"RC"},{"code":"29260","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING HAND OR FINGER","code_information":[{"code":"4200000002","type":"CDM"},{"code":"0700","type":"RC"},{"code":"29280","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL MLTLAYR COMPRES UPEPER ARM FOREARM HAND ETC","code_information":[{"code":"4200000004","type":"CDM"},{"code":"0420","type":"RC"},{"code":"29584","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOFEEDBACK TRAINING ANY MODALITY","code_information":[{"code":"4200000006","type":"CDM"},{"code":"0420","type":"RC"},{"code":"90901","type":"HCPCS"}],"standard_charges":[{"gross_charge":69.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANALITH REPOSITIONING PROC","code_information":[{"code":"4200000008","type":"CDM"},{"code":"0420","type":"RC"},{"code":"95992","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT APPL MODALITY 1 OR MORE AREAS HOT COLD PK","code_information":[{"code":"4200000009","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97010","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL MODALITY 1 OR MORE AREAS TRACTION MECHANICAL","code_information":[{"code":"4200000010","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97012","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT APPL MODALITY 1 OR MORE AREAS ELEC STIM UNATTENDED","code_information":[{"code":"4200000011","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97014","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL MODALITY 1 OR MORE AREAS VASOPNEUMATIC DEVICES","code_information":[{"code":"4200000012","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97016","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT APPL MODALITY 1 OR MORE AREAS PARAFFIN BATH","code_information":[{"code":"4200000013","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97018","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL MODALITY 1 OR MORE AREAS WHIRLPOOL","code_information":[{"code":"4200000014","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97022","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT APPL MODALITY 1 OR MORE AREAS ELEC STIM EA 15 MIN","code_information":[{"code":"4200000016","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97032","type":"HCPCS"}],"standard_charges":[{"gross_charge":381.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT APPL MODALITY 1 OR MORE AREAS IONTOPHORESIS EA 15 MIN","code_information":[{"code":"4200000017","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97033","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT APPL MODALITY 1 OR MORE AREAS US EA 15 MIN","code_information":[{"code":"4200000019","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97035","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT THER PROC 1 OR MORE AREAS EA 15 MIN EXERCISES","code_information":[{"code":"4200000020","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97110","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT THER PROC 1 OR MORE AREAS EA 15 MIN NEUROMUSC REEDUC","code_information":[{"code":"4200000021","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97112","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER PROC 1 OR MORE AREAS EA 15 MIN GAIT TRAIN W STAIR","code_information":[{"code":"4200000022","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97116","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT THER PROC 1 OR MORE AREAS EA 15 MIN MASSAGE","code_information":[{"code":"4200000023","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97124","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT MANUAL THERAPY TECHNIQUE 1 OR MORE REGIONS EA 15 MIN","code_information":[{"code":"4200000025","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97140","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER PROC GROUP 2 OR MORE INDIVIDUALS","code_information":[{"code":"4200000026","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":94.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT THER ACTIVITY DIRECT PT CONTACT EA 15 MIN","code_information":[{"code":"4200000027","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97530","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT SELF CARE HOME MGMNT TRAINING EA 15 MIN","code_information":[{"code":"4200000029","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97535","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMMUNITY WORK REINTEGRATION TRAIN EA 15 MIN","code_information":[{"code":"4200000030","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97537","type":"HCPCS"}],"standard_charges":[{"gross_charge":158.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT WHEELCHAIR MGMNT EA 15 MIN","code_information":[{"code":"4200000031","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97542","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WORK HARDENING CONDITIONING 1ST 2 HRS","code_information":[{"code":"4200000032","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97545","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WORK HARDENING CONDITIONING EA ADDL HR","code_information":[{"code":"4200000033","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97546","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT PHYSICAL PERFORMANCE TEST MEAS W RPT EA 15 MIN","code_information":[{"code":"4200000034","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97750","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT ORTHOTIC MGMNT TRAIN UPPER OR LOWER EXTREM EA 15 MIN","code_information":[{"code":"4200000035","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97760","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROSTHETIC TRAIN UPPER OR LOWER EXTREM EA 15 MIN","code_information":[{"code":"4200000036","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97761","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FITNESS SCREENING 30 MIN","code_information":[{"code":"4200000059","type":"CDM"},{"code":"0420","type":"RC"}],"standard_charges":[{"gross_charge":219.0,"setting":"both","modifiers":"SPE","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard | The modified price is presented in the standard charge value. | Modifier SPE: Modifier description not available"}]},{"description":"HC THERAPEUTIC IVNTJ W/FOCUS ON COGNITIVE FUNCTION","code_information":[{"code":"4200000064","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97127","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN","code_information":[{"code":"4200000065","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97763","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPI","code_information":[{"code":"4200000072","type":"CDM"},{"code":"0420","type":"RC"},{"code":"95851","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER PX 1/> AREAS EACH 15 MIN AQUA THER W/XERSS","code_information":[{"code":"4200000073","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97113","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CAREGIVER TRAINING STRATEGIES&TQ 1ST 30 MINUTES","code_information":[{"code":"4200000076","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97550","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN","code_information":[{"code":"4200000077","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97551","type":"HCPCS"}],"standard_charges":[{"gross_charge":58.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GROUP CAREGIVER TRAINING STRATEGIES & TECHNIQUE","code_information":[{"code":"4200000078","type":"CDM"},{"code":"0420","type":"RC"},{"code":"97552","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SENSORY INTEGRATION EA 15MIN","code_information":[{"code":"4210000000","type":"CDM"},{"code":"0421","type":"RC"},{"code":"97533","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS","code_information":[{"code":"4240000002","type":"CDM"},{"code":"0424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS","code_information":[{"code":"4240000003","type":"CDM"},{"code":"0424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYSICAL THERAPY EVALUATION HIGH COMPLEX 45 MINS","code_information":[{"code":"4240000004","type":"CDM"},{"code":"0424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYSICAL THERAPY RE EVAL EST PLAN CARE 20 MINS","code_information":[{"code":"4240000005","type":"CDM"},{"code":"0424","type":"RC"},{"code":"97164","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROM MEAS&REPRT HAND W/WO COMPARISON NORMAL SID","code_information":[{"code":"4300000000","type":"CDM"},{"code":"0430","type":"RC"},{"code":"95852","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS","code_information":[{"code":"4340000002","type":"CDM"},{"code":"0434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS","code_information":[{"code":"4340000003","type":"CDM"},{"code":"0434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS","code_information":[{"code":"4340000004","type":"CDM"},{"code":"0434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OCCUPATIONAL THER RE EVAL EST PLAN CARE 30 MINS","code_information":[{"code":"4340000005","type":"CDM"},{"code":"0434","type":"RC"},{"code":"97168","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRTMT SPEECH LANG VOICE COMM AUDITORY PROC IND","code_information":[{"code":"4400000000","type":"CDM"},{"code":"0440","type":"RC"},{"code":"92507","type":"HCPCS"}],"standard_charges":[{"gross_charge":516.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRTMT SPEECH LANG VOICE COMM AUDITORY 2 OR MORE IND","code_information":[{"code":"4400000001","type":"CDM"},{"code":"0440","type":"RC"},{"code":"92508","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRTMT SWALLOWING DYSFUNCTION ORAL FUNC FEEDING","code_information":[{"code":"4400000002","type":"CDM"},{"code":"0440","type":"RC"},{"code":"92526","type":"HCPCS"}],"standard_charges":[{"gross_charge":267.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER SVC SPEECH GENERATE DEVICE PROG AND MOD","code_information":[{"code":"4400000004","type":"CDM"},{"code":"0440","type":"RC"},{"code":"92609","type":"HCPCS"}],"standard_charges":[{"gross_charge":731.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PEDI SPEECH PROGRAM - 45 MIN SELF PAY","code_information":[{"code":"4400000005","type":"CDM"},{"code":"0440","type":"RC"}],"standard_charges":[{"gross_charge":137.0,"setting":"both","modifiers":"SPE","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard | The modified price is presented in the standard charge value. | Modifier SPE: Modifier description not available"}]},{"description":"HC EVAL OF SPEECH FLUENCY","code_information":[{"code":"4440000000","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":738.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL OF SPEECH SOUND PRODUCTION","code_information":[{"code":"4440000001","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":598.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL LANG COMPREHEND EXPRESS","code_information":[{"code":"4440000002","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1237.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL QUALITY VOICE RESONANCE","code_information":[{"code":"4440000003","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92524","type":"HCPCS"}],"standard_charges":[{"gross_charge":620.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL FITTING VOICE PROSTC DEV SUPLMNT ORAL SPEECH","code_information":[{"code":"4440000004","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92597","type":"HCPCS"}],"standard_charges":[{"gross_charge":357.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL RX NON SPEECH GEN AUGMNT ALT COMMUN DEV 1ST HR","code_information":[{"code":"4440000005","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92605","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL RX SPEECH GEN AUGMNT AND COMMUN DEV 1ST HR","code_information":[{"code":"4440000006","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92607","type":"HCPCS"}],"standard_charges":[{"gross_charge":436.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVAL ORAL AND PHARYNGEAL SWALLOWING FUNC","code_information":[{"code":"4440000007","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92610","type":"HCPCS"}],"standard_charges":[{"gross_charge":588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOTION FLURO EVAL LARYN CV REC","code_information":[{"code":"4440000008","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92611","type":"HCPCS"}],"standard_charges":[{"gross_charge":588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLEX FIBOPT NDSC EVAL SWALLOWING CV REC","code_information":[{"code":"4440000009","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92612","type":"HCPCS"}],"standard_charges":[{"gross_charge":311.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPEECH SCREENING","code_information":[{"code":"4440000012","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92700","type":"HCPCS"}],"standard_charges":[{"gross_charge":93.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASSESSMENT APHASIA W INTER AND RPT PER HR","code_information":[{"code":"4440000013","type":"CDM"},{"code":"0440","type":"RC"},{"code":"96105","type":"HCPCS"}],"standard_charges":[{"gross_charge":2146.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COGNITIVE PERFORMANCE TESTING","code_information":[{"code":"4440000038","type":"CDM"},{"code":"0444","type":"RC"},{"code":"96125","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES","code_information":[{"code":"4440000039","type":"CDM"},{"code":"0440","type":"RC"},{"code":"97129","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES","code_information":[{"code":"4440000040","type":"CDM"},{"code":"0440","type":"RC"},{"code":"97130","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVL FOR SPEECH DEV RX;EA AD30M","code_information":[{"code":"4440000041","type":"CDM"},{"code":"0444","type":"RC"},{"code":"92608","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMERGENCY DEPT VISIT LIMITED MINOR PROB","code_information":[{"code":"4500000000","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99281","type":"HCPCS"}],"standard_charges":[{"gross_charge":662.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMERGENCY DEPT VISIT LOW TO MODERATE SEVERITY","code_information":[{"code":"4500000001","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99282","type":"HCPCS"}],"standard_charges":[{"gross_charge":593.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMERGENCY DEPT VISIT MODERATE SEVERITY","code_information":[{"code":"4500000002","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99283","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMERGENCY DEPT VISIT HIGH URGENT SEVERITY","code_information":[{"code":"4500000003","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99284","type":"HCPCS"}],"standard_charges":[{"gross_charge":1160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMERGENCY DEPT VISIT HIGH SEVERITY AND THREAT FUNC","code_information":[{"code":"4500000004","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99285","type":"HCPCS"}],"standard_charges":[{"gross_charge":1550.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRITICAL CARE ILL INJURED PATIENT INIT 30 TO 74 MIN","code_information":[{"code":"4500000005","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99291","type":"HCPCS"}],"standard_charges":[{"gross_charge":6462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRITICAL CARE ILL INJURED PATIENT EA ADDL 30 MIN","code_information":[{"code":"4500000006","type":"CDM"},{"code":"0450","type":"RC"},{"code":"99292","type":"HCPCS"}],"standard_charges":[{"gross_charge":922.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSTETRICAL CARE,VAG DELIV ONLY","code_information":[{"code":"4500000008","type":"CDM"},{"code":"0510","type":"RC"},{"code":"59409","type":"HCPCS"}],"standard_charges":[{"gross_charge":6744.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT HIP DISLOCATION W ANESTHESIA","code_information":[{"code":"4500000009","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27252","type":"HCPCS"}],"standard_charges":[{"gross_charge":4488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GASTRIC INTUBATION THERAPEUTIC BY MD","code_information":[{"code":"4500000015","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43753","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROCTOSIGM RIGID WITH REMOVAL FB","code_information":[{"code":"4500000017","type":"CDM"},{"code":"0510","type":"RC"},{"code":"45307","type":"HCPCS"}],"standard_charges":[{"gross_charge":4058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE FECAL IMP OR FB W ANESTHESIA","code_information":[{"code":"4500000018","type":"CDM"},{"code":"0510","type":"RC"},{"code":"45915","type":"HCPCS"}],"standard_charges":[{"gross_charge":2793.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPORRHAPHY SUTURE INJURY VAGINA","code_information":[{"code":"4500000023","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57200","type":"HCPCS"}],"standard_charges":[{"gross_charge":3988.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TREATMNT OF INCOMP ABORTION","code_information":[{"code":"4500000024","type":"CDM"},{"code":"0510","type":"RC"},{"code":"59812","type":"HCPCS"}],"standard_charges":[{"gross_charge":5698.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH FOR STERILE URINE SPECIMN","code_information":[{"code":"4500000026","type":"CDM"},{"code":"0300","type":"RC"},{"code":"P9612","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX FEMUR SHAFT FX+MANIP","code_information":[{"code":"4500000031","type":"CDM"},{"code":"0450","type":"RC"},{"code":"27502","type":"HCPCS"}],"standard_charges":[{"gross_charge":4801.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPMTRY W VC EXPIRATORY FLO W WO MXML VOL VNT","code_information":[{"code":"4600000000","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94010","type":"HCPCS"}],"standard_charges":[{"gross_charge":587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCHODILATION RESPON SPIROMETRY PRE AND POST ADMIN","code_information":[{"code":"4600000001","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94060","type":"HCPCS"}],"standard_charges":[{"gross_charge":831.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCHOSPASM PROVOCATION EVAL MLT SPMTRY W ADMIN AGT","code_information":[{"code":"4600000002","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94070","type":"HCPCS"}],"standard_charges":[{"gross_charge":797.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VITAL CAPACITY TOT SEPARATE PROC","code_information":[{"code":"4600000003","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94150","type":"HCPCS"}],"standard_charges":[{"gross_charge":366.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MAX BREATHING CAPACITY MAXIMAL VOLUNTARY VENT","code_information":[{"code":"4600000004","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94200","type":"HCPCS"}],"standard_charges":[{"gross_charge":589.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RESPIRATORY FLOW VOL LOOP","code_information":[{"code":"4600000005","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94375","type":"HCPCS"}],"standard_charges":[{"gross_charge":701.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEMO EVAL OF PT UTILI AERSL GEN NEB INHLR IP","code_information":[{"code":"4600000008","type":"CDM"},{"code":"0410","type":"RC"},{"code":"94664","type":"HCPCS"}],"standard_charges":[{"gross_charge":333.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLETHYSMOGRAPHY LUNG VOL W WO AIRWAY RESIST","code_information":[{"code":"4600000009","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94726","type":"HCPCS"}],"standard_charges":[{"gross_charge":623.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GAS DILUT WASHOUT LUNG VOL W WO DISTRIB VENT AND VOLUME","code_information":[{"code":"4600000010","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94727","type":"HCPCS"}],"standard_charges":[{"gross_charge":465.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIFFUSING CAPACITY CARBON MONOXIDE MEMBRANE","code_information":[{"code":"4600000011","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94729","type":"HCPCS"}],"standard_charges":[{"gross_charge":315.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON INVASIVE EAR OR FINGER OX SINGLE DETER","code_information":[{"code":"4600000013","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94760","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON INVASIVE EAR PULSE OXIMETRY MULTIPLE DETER","code_information":[{"code":"4600000014","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94761","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON INVASIVE EAR PULSE OXIMETRY OVERNIGHT MONITOR","code_information":[{"code":"4600000015","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94762","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HELIOX TRTMT","code_information":[{"code":"4600000017","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94799","type":"HCPCS"}],"standard_charges":[{"gross_charge":515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CIRCADIAN RESPIRATORY PATTERN REC 12 TO 24 HR INFANT","code_information":[{"code":"4600000018","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94772","type":"HCPCS"}],"standard_charges":[{"gross_charge":1547.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CAR SEAT BED TESTING W INTER AND RPT EA ADDL 30 MIN","code_information":[{"code":"4600000020","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94781","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PULMONARY STRESS TESTING","code_information":[{"code":"4600000026","type":"CDM"},{"code":"0460","type":"RC"},{"code":"94618","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NASOPHARYNGOSCOPY W ENDOSCOPE SPX","code_information":[{"code":"4710000001","type":"CDM"},{"code":"0510","type":"RC"},{"code":"92511","type":"HCPCS"}],"standard_charges":[{"gross_charge":549.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AEP SCREENING AUDITORY POTENTIAL W/STIMULI AUTO ANALYSIS","code_information":[{"code":"4710000038","type":"CDM"},{"code":"0471","type":"RC"},{"code":"92650","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIOPULMONARY RESUSCITATION","code_information":[{"code":"4800000000","type":"CDM"},{"code":"0480","type":"RC"},{"code":"92950","type":"HCPCS"}],"standard_charges":[{"gross_charge":1683.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL","code_information":[{"code":"4800000001","type":"CDM"},{"code":"0480","type":"RC"},{"code":"92960","type":"HCPCS"}],"standard_charges":[{"gross_charge":1150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIOVERSION ELECTIVE ARRHYTHMIA INTERNAL SPX","code_information":[{"code":"4800000002","type":"CDM"},{"code":"0480","type":"RC"},{"code":"92961","type":"HCPCS"}],"standard_charges":[{"gross_charge":2079.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUMINAL CORONARY THROMBECTOMY MECHANICAL","code_information":[{"code":"4800000003","type":"CDM"},{"code":"0481","type":"RC"},{"code":"92973","type":"HCPCS"}],"standard_charges":[{"gross_charge":501.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER","code_information":[{"code":"4800000008","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93279","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAM EVAL IMPLANTABLE IN PRSN DUAL LD PACER","code_information":[{"code":"4800000009","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93280","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAM EVAL IMPLTBL IN PERSON 1 LEAD DFB","code_information":[{"code":"4800000011","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93282","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAM EVAL IMPLTBL IN PERSON DUAL LEAD DFB","code_information":[{"code":"4800000012","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93283","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAM EVAL IMPLTBL IN PERSON MULT LEAD DFB","code_information":[{"code":"4800000013","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93284","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYS","code_information":[{"code":"4800000014","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93285","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROGATION EVAL IN PERSON 1 DUAL MULT LEAD PM","code_information":[{"code":"4800000017","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93288","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERR DEV EVAL ANALY REVIEW RPRT BY PHYSC OR PROF","code_information":[{"code":"4800000018","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93289","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROGATION EVAL IMPLANTABLE CARDIOVASC MONIT SYS","code_information":[{"code":"4800000019","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93290","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROGATION EVAL IN PERSON ILR SYS","code_information":[{"code":"4800000020","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93291","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERR EVAL REMOTE UP TO 90 DAYS TECHNICIAN REVIEW","code_information":[{"code":"4800000022","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93296","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV DOP VEL AND OR PRESS C FLO RSRV MEAS EA ADDL VESSEL","code_information":[{"code":"4800000025","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93572","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECTROPHYSIOLOGIC EVAL","code_information":[{"code":"4800000038","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93640","type":"HCPCS"}],"standard_charges":[{"gross_charge":1196.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRACARDIAC CATH ABLATION ATRIOVENT NODE FUNCTION","code_information":[{"code":"4800000041","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93650","type":"HCPCS"}],"standard_charges":[{"gross_charge":23561.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECTROPHYSIOLOGIC EVAL W ABLATION SUPRAVENT ARRHYTHMIA","code_information":[{"code":"4800000042","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93653","type":"HCPCS"}],"standard_charges":[{"gross_charge":76173.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMP ELECTROPHYSIOLOGIC EVAL","code_information":[{"code":"4800000045","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93656","type":"HCPCS"}],"standard_charges":[{"gross_charge":73597.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AMBULATORY BP MONITOR ANALYSIS","code_information":[{"code":"4800000050","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93788","type":"HCPCS"}],"standard_charges":[{"gross_charge":333.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASPIRATION THROMBECTOMY","code_information":[{"code":"4800000051","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":557.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RHC 1 TRVEN ELTRD PERM PCM OR IMPLTBL DFB","code_information":[{"code":"4800000053","type":"CDM"},{"code":"0510","type":"RC"},{"code":"33218","type":"HCPCS"}],"standard_charges":[{"gross_charge":11300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INS/REPLCMT SUBQ IMPLT DEFIB SYSTEM W/SUBQ ELTRD","code_information":[{"code":"4800000064","type":"CDM"},{"code":"0481","type":"RC"},{"code":"33270","type":"HCPCS"}],"standard_charges":[{"gross_charge":99551.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERRO EVAL F2F IMPLT SUBQ LEAD DEFIB","code_information":[{"code":"4800000072","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93261","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERIPHERAL ARTERIAL DISEASE REHAB PER SESSION","code_information":[{"code":"4800000074","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93668","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MYOCRD STRAIN IMG SPECKLE TRCK ASSMT MYOCRD MECH","code_information":[{"code":"4800000077","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93356","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ PULM ART REVSC STNT 1ST ABN CONN UNILATERAL","code_information":[{"code":"4800000092","type":"CDM"},{"code":"0480","type":"RC"},{"code":"33902","type":"HCPCS"}],"standard_charges":[{"gross_charge":63974.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROGATION VAD IN PRSON W/PHYS/QHP ANALYSIS","code_information":[{"code":"4800000127","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93750","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC N-INVAS EST C FFR AUGMNT SW ALYS CTA I&R PHY/QHP","code_information":[{"code":"4800000139","type":"CDM"},{"code":"0350","type":"RC"},{"code":"75580","type":"HCPCS"}],"standard_charges":[{"gross_charge":3625.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER ACTIVATION IMPL PHRENIC NRV STIMULATOR SYS","code_information":[{"code":"4800000141","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93150","type":"HCPCS"}],"standard_charges":[{"gross_charge":331.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROG&PROG IMPL PHRENIC NRV STIMULATOR SYS","code_information":[{"code":"4800000142","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93151","type":"HCPCS"}],"standard_charges":[{"gross_charge":331.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROG&PROG IPNSS DURING POLYSOMNOGRAPHY","code_information":[{"code":"4800000143","type":"CDM"},{"code":"0480","type":"RC"},{"code":"93152","type":"HCPCS"}],"standard_charges":[{"gross_charge":932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC QTC INTERVAL AUGMNT ALG ALYS XTRNL MOBILE ECG","code_information":[{"code":"4800000152","type":"CDM"},{"code":"0480","type":"RC"},{"code":"0902T","type":"HCPCS"}],"standard_charges":[{"gross_charge":401.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROGRAMMING DEVICE EVAL IMPL CCM-D SYS IN PERSON","code_information":[{"code":"4800000153","type":"CDM"},{"code":"0480","type":"RC"},{"code":"0926T","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HCR INTERROG DEV EVAL IMPL CCM-D SYSTEM IN PERSON","code_information":[{"code":"4800000154","type":"CDM"},{"code":"0480","type":"RC"},{"code":"0927T","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOTE INTERROG DEV EVAL CCM-D SYS <90D TECH","code_information":[{"code":"4800000156","type":"CDM"},{"code":"0480","type":"RC"},{"code":"0929T","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON SELECT CATH PLACE THORACIC AORTA W ANGIOGRAPHY","code_information":[{"code":"4810000009","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36221","type":"HCPCS"}],"standard_charges":[{"gross_charge":7538.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SECOND PERC TRANSLUMINAL MCHNL THRMBC NON CORONARY","code_information":[{"code":"4810000011","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37186","type":"HCPCS"}],"standard_charges":[{"gross_charge":1246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH THER THROMBOLYSIS ARTERIAL OR VENOUS CONTD","code_information":[{"code":"4810000012","type":"CDM"},{"code":"0481","type":"RC"},{"code":"37213","type":"HCPCS"}],"standard_charges":[{"gross_charge":3837.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUMINAL CORONARY ATHERECTOMY EA ADDL BRANCH","code_information":[{"code":"4810000020","type":"CDM"},{"code":"0481","type":"RC"},{"code":"92934","type":"HCPCS"}],"standard_charges":[{"gross_charge":4723.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUMINAL CORONARY BYP GRAFT REVASC 1 VESSEL","code_information":[{"code":"4810000021","type":"CDM"},{"code":"0481","type":"RC"},{"code":"92937","type":"HCPCS"}],"standard_charges":[{"gross_charge":34022.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUMINAL CORONARY TOT OCCLUS REVASC MI 1 VESS","code_information":[{"code":"4810000022","type":"CDM"},{"code":"0481","type":"RC"},{"code":"92941","type":"HCPCS"}],"standard_charges":[{"gross_charge":33300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRAVASC US CORONARY INTER AND RPT ADD VESSEL","code_information":[{"code":"4810000027","type":"CDM"},{"code":"0481","type":"RC"},{"code":"92979","type":"HCPCS"}],"standard_charges":[{"gross_charge":442.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LT HEART CATH W INJ L VENTRICULOGRAPHY IMAGE","code_information":[{"code":"4810000029","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93452","type":"HCPCS"}],"standard_charges":[{"gross_charge":9987.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RT AND LT HEART CATH W INJ LT VENTRICULOG IMAGE","code_information":[{"code":"4810000030","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93453","type":"HCPCS"}],"standard_charges":[{"gross_charge":9987.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH PLACEMENT AND INJ CORONARY ART ANGIO IMAGE","code_information":[{"code":"4810000031","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93454","type":"HCPCS"}],"standard_charges":[{"gross_charge":9987.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT FLOW DIRECTED CATH FOR MONITORING","code_information":[{"code":"4810000041","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93503","type":"HCPCS"}],"standard_charges":[{"gross_charge":4823.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSCATH PLACE DES STENT","code_information":[{"code":"4810000052","type":"CDM"},{"code":"0481","type":"RC"},{"code":"C9600","type":"HCPCS"}],"standard_charges":[{"gross_charge":35213.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUM ATH W STENT","code_information":[{"code":"4810000054","type":"CDM"},{"code":"0481","type":"RC"},{"code":"C9602","type":"HCPCS"}],"standard_charges":[{"gross_charge":63974.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUM STENT SINGLE V","code_information":[{"code":"4810000055","type":"CDM"},{"code":"0481","type":"RC"},{"code":"C9604","type":"HCPCS"}],"standard_charges":[{"gross_charge":35213.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUM ACUTE MI SINGLE","code_information":[{"code":"4810000056","type":"CDM"},{"code":"0481","type":"RC"},{"code":"C9606","type":"HCPCS"}],"standard_charges":[{"gross_charge":37024.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACEMENT OCCLUSIVE DEV VEIN ART","code_information":[{"code":"4810000057","type":"CDM"},{"code":"0481","type":"RC"},{"code":"G0269","type":"HCPCS"}],"standard_charges":[{"gross_charge":311.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH PLACE IV STENT CRV CRTD ART WO EMBO PROTEC","code_information":[{"code":"4810000061","type":"CDM"},{"code":"0481","type":"RC"},{"code":"37216","type":"HCPCS"}],"standard_charges":[{"gross_charge":4583.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT SELECT RIGHT VENT/ATRIAL ANGIO DURING HEART CATH","code_information":[{"code":"4810000068","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93566","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC D-E COR REVASC T CABG B","code_information":[{"code":"4810000073","type":"CDM"},{"code":"0481","type":"RC"},{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"gross_charge":27380.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC D-E COR REVASC CHRO SIN","code_information":[{"code":"4810000074","type":"CDM"},{"code":"0481","type":"RC"},{"code":"C9607","type":"HCPCS"}],"standard_charges":[{"gross_charge":63974.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ THRMBC NFS DIAL CIRCUIT TRLUML BALO ANGIOP","code_information":[{"code":"4810000080","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36905","type":"HCPCS"}],"standard_charges":[{"gross_charge":23399.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ THRMBC NFS DIAL CIRCUIT TCAT PLMT IV STENT","code_information":[{"code":"4810000081","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36906","type":"HCPCS"}],"standard_charges":[{"gross_charge":40683.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRLUML BALO ANGIOP CTR DIALYSIS SEG W IMG SANDI","code_information":[{"code":"4810000082","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36907","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TCAT PLMT IV STENT CTR DIALYSIS SEG W IMG SANDI","code_information":[{"code":"4810000083","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36908","type":"HCPCS"}],"standard_charges":[{"gross_charge":7574.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ TRANSCATH CLS PARAVALVR LEAK 1 AORTIC VALVE","code_information":[{"code":"4810000085","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93591","type":"HCPCS"}],"standard_charges":[{"gross_charge":55755.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ TRANSCATH CLS PARAVALVR LEAK EACH OCCLS DEV","code_information":[{"code":"4810000086","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93592","type":"HCPCS"}],"standard_charges":[{"gross_charge":1111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO CATH DIALYSIS CIRCUIT DX ANGRPH FLUOR SANDI","code_information":[{"code":"4810000087","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36901","type":"HCPCS"}],"standard_charges":[{"gross_charge":2225.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO CATH DIALYSIS CIRCUIT W TRLUML BALO ANGIOP","code_information":[{"code":"4810000088","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36902","type":"HCPCS"}],"standard_charges":[{"gross_charge":11240.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO CATH DIALYSIS CIRCUIT W TCAT PLMT IV STENT","code_information":[{"code":"4810000089","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36903","type":"HCPCS"}],"standard_charges":[{"gross_charge":23399.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ THRMBC NFS DIALYSIS CIRCUIT IMG DX ANGRPH","code_information":[{"code":"4810000090","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36904","type":"HCPCS"}],"standard_charges":[{"gross_charge":16912.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIALYSIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG SANDI","code_information":[{"code":"4810000091","type":"CDM"},{"code":"0481","type":"RC"},{"code":"36909","type":"HCPCS"}],"standard_charges":[{"gross_charge":571.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR","code_information":[{"code":"4810000100","type":"CDM"},{"code":"0481","type":"RC"},{"code":"33289","type":"HCPCS"}],"standard_charges":[{"gross_charge":107716.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 3D ECHO IMG&PST-PXESSING TEE/TTE CGEN CAR ANOMAL","code_information":[{"code":"4810000115","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93319","type":"HCPCS"}],"standard_charges":[{"gross_charge":640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC R HRT CATH CHD W/IMG CATH TRGT ZONE NML NT CONNJ","code_information":[{"code":"4810000116","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93593","type":"HCPCS"}],"standard_charges":[{"gross_charge":9987.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DURING CARDIAC CATH SLCTV PULM VEN ANGIO EA DSTNT PUL VN","code_information":[{"code":"4810000127","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93574","type":"HCPCS"}],"standard_charges":[{"gross_charge":1000.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECMO LAVA VIA TRANSSEPTAL PUNCTURE","code_information":[{"code":"4810000129","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRACARDIAC ECHOCARDIOGRAPHY/ICE INCL IMAGING S&I","code_information":[{"code":"4810000151","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TCAT INSJ PERM 1CHMBR LDLS PACEMAKER R ATRIAL","code_information":[{"code":"4810000155","type":"CDM"},{"code":"0481","type":"RC"},{"code":"0823T","type":"HCPCS"}],"standard_charges":[{"gross_charge":59215.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIONEURO ABLATION","code_information":[{"code":"4810000167","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ TCAT THER RX DLVR NTRAC RX BALO 1 MAJ C ART","code_information":[{"code":"4810000168","type":"CDM"},{"code":"0481","type":"RC"},{"code":"0913T","type":"HCPCS"}],"standard_charges":[{"gross_charge":17704.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ TCAT THER RX DLVR NTRAC RX BALO SEPARATE","code_information":[{"code":"4810000169","type":"CDM"},{"code":"0481","type":"RC"},{"code":"0914T","type":"HCPCS"}],"standard_charges":[{"gross_charge":1035.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TCAT RMVL/DEBULK ICAR MASS SUCTION DEVICE PERQ","code_information":[{"code":"4810000184","type":"CDM"},{"code":"0481","type":"RC"},{"code":"0644T","type":"HCPCS"}],"standard_charges":[{"gross_charge":17704.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UNLISTED CARDIOVASCULAR SERVICE/PROCEDURE","code_information":[{"code":"4810000186","type":"CDM"},{"code":"0481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":557.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIOVASCULAR STRESS TEST EXERCISE WO INTER AND RPT","code_information":[{"code":"4820000000","type":"CDM"},{"code":"0482","type":"RC"},{"code":"93017","type":"HCPCS"}],"standard_charges":[{"gross_charge":1207.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR CONGEN COMP W CONT","code_information":[{"code":"4830000000","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8921","type":"HCPCS"}],"standard_charges":[{"gross_charge":2613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR CONGEN LTD W CONTRAST","code_information":[{"code":"4830000001","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8922","type":"HCPCS"}],"standard_charges":[{"gross_charge":2842.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W DOP COMP W CONT","code_information":[{"code":"4830000002","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8929","type":"HCPCS"}],"standard_charges":[{"gross_charge":2304.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W IMAGE LTD W CONT","code_information":[{"code":"4830000004","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8924","type":"HCPCS"}],"standard_charges":[{"gross_charge":1555.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH W CONT","code_information":[{"code":"4830000005","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8925","type":"HCPCS"}],"standard_charges":[{"gross_charge":2467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH W IMAGE INTER AND RPT W CONT","code_information":[{"code":"4830000006","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93314","type":"HCPCS"}],"standard_charges":[{"gross_charge":430.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH CONGEN W CONT","code_information":[{"code":"4830000007","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8926","type":"HCPCS"}],"standard_charges":[{"gross_charge":2672.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO DOP WAVE W SPECTRAL COMP","code_information":[{"code":"4830000009","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93320","type":"HCPCS"}],"standard_charges":[{"gross_charge":377.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO DOP CLR FLW VELOCITY MAP","code_information":[{"code":"4830000011","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93325","type":"HCPCS"}],"standard_charges":[{"gross_charge":602.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W STRESS W CONT","code_information":[{"code":"4830000012","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8928","type":"HCPCS"}],"standard_charges":[{"gross_charge":2582.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W STRESS CONT MONIT W CONT","code_information":[{"code":"4830000013","type":"CDM"},{"code":"0483","type":"RC"},{"code":"C8930","type":"HCPCS"}],"standard_charges":[{"gross_charge":2502.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR CONGEN COMP WO CONT","code_information":[{"code":"4830000024","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93303","type":"HCPCS"}],"standard_charges":[{"gross_charge":1471.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR CONGEN LTD WO CONTRAST","code_information":[{"code":"4830000025","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93304","type":"HCPCS"}],"standard_charges":[{"gross_charge":1663.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W DOP COMP WO CONT","code_information":[{"code":"4830000026","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93306","type":"HCPCS"}],"standard_charges":[{"gross_charge":1847.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W IMAGE LTD WO CONT","code_information":[{"code":"4830000027","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93308","type":"HCPCS"}],"standard_charges":[{"gross_charge":932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH WO CONT","code_information":[{"code":"4830000028","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93312","type":"HCPCS"}],"standard_charges":[{"gross_charge":2096.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH CONGEN WO CONT","code_information":[{"code":"4830000029","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93315","type":"HCPCS"}],"standard_charges":[{"gross_charge":1559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH MONITER PROBE PLACE WO CONT","code_information":[{"code":"4830000030","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93318","type":"HCPCS"}],"standard_charges":[{"gross_charge":1780.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W STRESS CONT MONIT WO CONT","code_information":[{"code":"4830000031","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93351","type":"HCPCS"}],"standard_charges":[{"gross_charge":1797.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W IMAGE WO DOP COMP WO CONT","code_information":[{"code":"4830000032","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93307","type":"HCPCS"}],"standard_charges":[{"gross_charge":1508.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSESOPH PROBE PLACEMT","code_information":[{"code":"4830000033","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93313","type":"HCPCS"}],"standard_charges":[{"gross_charge":1559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO DOP WAVE W SPECTRAL LTD","code_information":[{"code":"4830000036","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93321","type":"HCPCS"}],"standard_charges":[{"gross_charge":377.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECHO TRANSTHOR W STRESS WO CONT","code_information":[{"code":"4830000038","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93350","type":"HCPCS"}],"standard_charges":[{"gross_charge":1437.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM INTERROG SCRMS <30 D PHYS/QHP","code_information":[{"code":"4830000042","type":"CDM"},{"code":"0483","type":"RC"},{"code":"93298","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIR WO IMAGE GUIDANCE","code_information":[{"code":"5100000000","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10021","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMAGE GUIDED FLUID COLL DRAIN BY CATH","code_information":[{"code":"5100000002","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10030","type":"HCPCS"}],"standard_charges":[{"gross_charge":2540.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN OF ABSCESS SIMP OR SINGLE","code_information":[{"code":"5100000004","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10060","type":"HCPCS"}],"standard_charges":[{"gross_charge":315.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN OF ABSCESS COMP OR MULT","code_information":[{"code":"5100000005","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10061","type":"HCPCS"}],"standard_charges":[{"gross_charge":492.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN OF PILONIDAL CYST SIMP","code_information":[{"code":"5100000006","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10080","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN OF PILONIDAL CYST COMP","code_information":[{"code":"5100000007","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10081","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND REM OF FOREIGN BOD SUBC TISSUE  SIMP","code_information":[{"code":"5100000008","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10120","type":"HCPCS"}],"standard_charges":[{"gross_charge":652.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND REM OF FOREIGN BODY SUBC TISSUE COMP","code_information":[{"code":"5100000009","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10121","type":"HCPCS"}],"standard_charges":[{"gross_charge":2905.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN OF HEMAT SEROMA OR FLUID COLL","code_information":[{"code":"5100000010","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10140","type":"HCPCS"}],"standard_charges":[{"gross_charge":1729.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PUNCTURE ASPIR OF ABSCESS HEMAT BULLA OR CYST","code_information":[{"code":"5100000011","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10160","type":"HCPCS"}],"standard_charges":[{"gross_charge":492.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN COMP POST OP WOUND INFECTION","code_information":[{"code":"5100000012","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10180","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE OF EXTEN ECZEMATOUS OR INF SKIN UP TO 10%","code_information":[{"code":"5100000013","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11000","type":"HCPCS"}],"standard_charges":[{"gross_charge":652.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE W REM OF FOREIGN MATRL SKIN AND SUBC TISS","code_information":[{"code":"5100000014","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11010","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE W REM OF FOREIGN MATRL SKIN MUSC FASC AND BONE","code_information":[{"code":"5100000015","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11012","type":"HCPCS"}],"standard_charges":[{"gross_charge":3017.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE SUBC TISSUE FIRST 20 SQ CM OR LESS","code_information":[{"code":"5100000016","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11042","type":"HCPCS"}],"standard_charges":[{"gross_charge":782.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE MUSC AND OR FASC FIRST 20 SQ CM","code_information":[{"code":"5100000017","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11043","type":"HCPCS"}],"standard_charges":[{"gross_charge":1694.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE BONE MUSC AND OR FASC FIRST 20 SQ CM","code_information":[{"code":"5100000018","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11044","type":"HCPCS"}],"standard_charges":[{"gross_charge":3732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE SUBC TISSUE EA ADDL 20 SQ CM","code_information":[{"code":"5100000019","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11045","type":"HCPCS"}],"standard_charges":[{"gross_charge":782.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE MUSC AND OR FASC EA ADDL 20 SQ CM","code_information":[{"code":"5100000020","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11046","type":"HCPCS"}],"standard_charges":[{"gross_charge":1694.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE BONE MUSC AND OR FASC EA ADDL 20 SQ CM","code_information":[{"code":"5100000021","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11047","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PARING OR CUTTING BEN HYPER SINGLE LESION","code_information":[{"code":"5100000022","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11055","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PARING OR CUTTING BEN HYPER 2 TO 4 LESIONS","code_information":[{"code":"5100000023","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11056","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PARING OR CUTTING BEN HYPER OVER 4 LESIONS","code_information":[{"code":"5100000024","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11057","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF SKIN TAGS 1 TO 15 LESIONS","code_information":[{"code":"5100000027","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11200","type":"HCPCS"}],"standard_charges":[{"gross_charge":434.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHAVING SCALP NECK HANDS ETC SINGLE LESION 0.5 CM OR LESS","code_information":[{"code":"5100000033","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11305","type":"HCPCS"}],"standard_charges":[{"gross_charge":617.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SHAVING SCALP NECK HANDS ETC SINGLE LESION OVER 2.0 CM","code_information":[{"code":"5100000036","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11308","type":"HCPCS"}],"standard_charges":[{"gross_charge":737.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES TRUNK ARMS OR LEGS 0.5 CM OR LESS","code_information":[{"code":"5100000041","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11400","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES TRUNK ARMS OR LEGS 0.6 TO 1.0 CM","code_information":[{"code":"5100000042","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11401","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES TRUNK ARMS OR LEGS 1.1 TO 2.0 CM","code_information":[{"code":"5100000043","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11402","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES TRUNK ARMS OR LEGS 2.1 TO 3.0 CM","code_information":[{"code":"5100000044","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11403","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES TRUNK ARMS OR LEGS 3.1 TO 4.0 CM","code_information":[{"code":"5100000045","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11404","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES TRUNK ARMS OR LEGS OVER 4.0 CM","code_information":[{"code":"5100000046","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11406","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES SCALP NECK HANDS ETC 0.5 CM OR LESS","code_information":[{"code":"5100000047","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11420","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES SCALP NECK HANDS ETC 0.6 TO 1.0 CM","code_information":[{"code":"5100000048","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11421","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES SCALP NECK HANDS ETC 1.1 TO 2.0 CM","code_information":[{"code":"5100000049","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11422","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES SCALP NECK HANDS ETC 2.1 TO 3.0 CM","code_information":[{"code":"5100000050","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11423","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES SCALP NECK HANDS ETC 3.1 TO 4.0 CM","code_information":[{"code":"5100000051","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11424","type":"HCPCS"}],"standard_charges":[{"gross_charge":3844.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES SCALP NECK HANDS ETC OVER 4.0 CM","code_information":[{"code":"5100000052","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11426","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES FACE EARS NOSE ETC 0.6 TO 1.0 CM","code_information":[{"code":"5100000054","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11441","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES FACE EARS NOSE ETC 1.1 TO 2.0 CM","code_information":[{"code":"5100000055","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11442","type":"HCPCS"}],"standard_charges":[{"gross_charge":1621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC BEN LES FACE EARS NOSE ETC 2.1 TO 3.0 CM","code_information":[{"code":"5100000056","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11443","type":"HCPCS"}],"standard_charges":[{"gross_charge":2419.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES TRUNK ARMS OR LEGS 0.5 CM OR LESS","code_information":[{"code":"5100000059","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES TRUNK ARMS OR LEGS 0.6 TO 1.0 CM","code_information":[{"code":"5100000060","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11601","type":"HCPCS"}],"standard_charges":[{"gross_charge":1022.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES TRUNK ARMS OR LEGS 1.1 TO 2.0 CM","code_information":[{"code":"5100000061","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11602","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES TRUNK ARMS OR LEGS 2.1 TO 3.0 CM","code_information":[{"code":"5100000062","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11603","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES TRUNK ARMS OR LEGS 3.1 TO 4.0 CM","code_information":[{"code":"5100000063","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11604","type":"HCPCS"}],"standard_charges":[{"gross_charge":3796.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES TRUNK ARMS OR LEGS OVER 4.0 CM","code_information":[{"code":"5100000064","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11606","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES SCALP NECK HANDS ETC OVER 4.0 CM","code_information":[{"code":"5100000070","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11626","type":"HCPCS"}],"standard_charges":[{"gross_charge":5085.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES FACE EARS NOSE ETC 1.1 TO 2.0 CM","code_information":[{"code":"5100000073","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11642","type":"HCPCS"}],"standard_charges":[{"gross_charge":1252.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC MAL LES FACE EARS NOSE ETC 3.1 TO 4.0 CM","code_information":[{"code":"5100000075","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11644","type":"HCPCS"}],"standard_charges":[{"gross_charge":3855.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRIMMING OF NONDYSTROPHIC NAILS ANY NUMBER","code_information":[{"code":"5100000077","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11719","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE OF NAILS BY ANY METHOD 1 TO 5","code_information":[{"code":"5100000078","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11720","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE OF NAILS BY ANY METHOD 6 OR MORE","code_information":[{"code":"5100000079","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11721","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AVULSION NAIL PLATE PART OR COMPLETE SIMPLE SINGLE","code_information":[{"code":"5100000080","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11730","type":"HCPCS"}],"standard_charges":[{"gross_charge":445.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AVULSION NAIL PLATE PART OR COMPLETE SIMPLE EA ADDL","code_information":[{"code":"5100000081","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11732","type":"HCPCS"}],"standard_charges":[{"gross_charge":575.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EVACUATION SUBUNGUAL HEMATOMA","code_information":[{"code":"5100000082","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11740","type":"HCPCS"}],"standard_charges":[{"gross_charge":409.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC NAIL AND MATRIX PART OR COMPL PERM REM","code_information":[{"code":"5100000083","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11750","type":"HCPCS"}],"standard_charges":[{"gross_charge":445.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP OF NAIL BED","code_information":[{"code":"5100000086","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11760","type":"HCPCS"}],"standard_charges":[{"gross_charge":645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC WEDGE EXCIS OF SKIN OF NAIL FOLD","code_information":[{"code":"5100000088","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11765","type":"HCPCS"}],"standard_charges":[{"gross_charge":489.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC PILONIDAL CYST OR SINUS SIMPLE","code_information":[{"code":"5100000089","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11770","type":"HCPCS"}],"standard_charges":[{"gross_charge":5698.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ INTRALESIONAL UP TO AND 7 LESIONS","code_information":[{"code":"5100000090","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11900","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUBC INJ OF FILLING MATRL 1.1 TO 5.0 CC","code_information":[{"code":"5100000095","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11951","type":"HCPCS"}],"standard_charges":[{"gross_charge":1836.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT NON BIODEGRADABLE DRUG DELIVERY IMPL","code_information":[{"code":"5100000099","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11981","type":"HCPCS"}],"standard_charges":[{"gross_charge":588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM NON BIODEGRADABLE DRUG DELIVERY IMPL","code_information":[{"code":"5100000100","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11982","type":"HCPCS"}],"standard_charges":[{"gross_charge":818.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND SCALP NECK TRUNK ETC 2.5 CM OR LESS","code_information":[{"code":"5100000102","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12001","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND SCALP NECK TRUNK ETC 2.6 TO 7.5 CM","code_information":[{"code":"5100000103","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12002","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND SCALP NECK TRUNK ETC 7.6 TO 12.5 CM","code_information":[{"code":"5100000104","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12004","type":"HCPCS"}],"standard_charges":[{"gross_charge":1670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND SCALP NECK TRUNK ETC  12.6 TO 20.0 CM","code_information":[{"code":"5100000105","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12005","type":"HCPCS"}],"standard_charges":[{"gross_charge":1599.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND SCALP NECK TRUNK ETC  20.1 TO 30.0 CM","code_information":[{"code":"5100000106","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12006","type":"HCPCS"}],"standard_charges":[{"gross_charge":3678.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND SCALP NECK TRUNK ETC OVER 30.0 CM","code_information":[{"code":"5100000107","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12007","type":"HCPCS"}],"standard_charges":[{"gross_charge":3678.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND FACE EARS NOSE ETC 2.5 CM OR LESS","code_information":[{"code":"5100000108","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12011","type":"HCPCS"}],"standard_charges":[{"gross_charge":1670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND FACE EARS NOSE ETC 2.6 TO 5.0 CM","code_information":[{"code":"5100000109","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12013","type":"HCPCS"}],"standard_charges":[{"gross_charge":1670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND FACE EARS NOSE ETC 5.1 TO 7.5 CM","code_information":[{"code":"5100000110","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12014","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND FACE EARS NOSE ETC 7.6 TO 12.5 CM","code_information":[{"code":"5100000111","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12015","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIMP REP WOUND FACE EARS NOSE ETC 12.6 TO 20.0 CM","code_information":[{"code":"5100000112","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12016","type":"HCPCS"}],"standard_charges":[{"gross_charge":3790.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TREAT OF SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE","code_information":[{"code":"5100000113","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12020","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TREAT OF SUPERFICIAL WOUND DEHISCENCE W PACKING","code_information":[{"code":"5100000114","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12021","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED SCALP AXILLAE TRUNK ETC 2.5 CM OR LESS","code_information":[{"code":"5100000115","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12031","type":"HCPCS"}],"standard_charges":[{"gross_charge":676.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED SCALP AXILLAE TRUNK ETC 2.6 TO 7.5 CM","code_information":[{"code":"5100000116","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12032","type":"HCPCS"}],"standard_charges":[{"gross_charge":668.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED SCALP AXILLAE TRUNK ETC 7.6 TO 12.5 CM","code_information":[{"code":"5100000117","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12034","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED SCALP AXILLAE TRUNK ETC 12.6 TO 20.0 CM","code_information":[{"code":"5100000118","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12035","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED SCALP AXILLAE TRUNK ETC 20.1 TO 30.0 CM","code_information":[{"code":"5100000119","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12036","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED NECK HANDS FEET ETC 2.5 CM OR LESS","code_information":[{"code":"5100000121","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12041","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED NECK HANDS FEET ETC 2.6 TO 7.5 CM","code_information":[{"code":"5100000122","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12042","type":"HCPCS"}],"standard_charges":[{"gross_charge":980.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED NECK HANDS FEET ETC 12.6 TO 20.0 CM","code_information":[{"code":"5100000123","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12045","type":"HCPCS"}],"standard_charges":[{"gross_charge":980.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED FACE EARS NOSE ETC 2.5 CM OR LESS","code_information":[{"code":"5100000124","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12051","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED FACE EARS NOSE ETC 2.6 TO 5.0 CM","code_information":[{"code":"5100000125","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12052","type":"HCPCS"}],"standard_charges":[{"gross_charge":951.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED FACE EARS NOSE ETC 12.6 TO 20.CM","code_information":[{"code":"5100000126","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12055","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPAIR COMPLEX TRUNK 1.1 TO 2.5 CM","code_information":[{"code":"5100000127","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13100","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX SCALP ARMS AND OR LEGS 2.6 TO 7.5 CM","code_information":[{"code":"5100000130","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13121","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX FOREHEAD CHEEKS CHIN ETC 1.1 TO 2.5 CM","code_information":[{"code":"5100000131","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13131","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX FOREHEAD CHEEKS CHIN ETC 2.6 TO 7.5 CM","code_information":[{"code":"5100000132","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13132","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX FOREHEAD CHEEKS CHIN ETC EA ADDL 5 CM","code_information":[{"code":"5100000133","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13133","type":"HCPCS"}],"standard_charges":[{"gross_charge":815.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX EYELIDS NOSE EAR LIP 1.1 TO 2.5 CM","code_information":[{"code":"5100000134","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13151","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX EYELIDS NOSE EAR LIP 2.6 TO 7.5 CM","code_information":[{"code":"5100000135","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13152","type":"HCPCS"}],"standard_charges":[{"gross_charge":1858.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJACENT TISS TRSFR TRUNK DEFECT 10 CM OR LESS","code_information":[{"code":"5100000137","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14000","type":"HCPCS"}],"standard_charges":[{"gross_charge":4469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJACENT TISS TRSFR TRUNK DEFECT 10.1 TO 30.0 CM","code_information":[{"code":"5100000138","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14001","type":"HCPCS"}],"standard_charges":[{"gross_charge":6870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJACENT TISS TRSFR SCALP ARMS OR LEGS 10 CM OR LESS","code_information":[{"code":"5100000139","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14020","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJACENT TISS TRSFR SCALP ARMS OR LEGS 10.1 TO 30.0 CM","code_information":[{"code":"5100000140","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14021","type":"HCPCS"}],"standard_charges":[{"gross_charge":6706.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJACENT TISS TRSFR FOREHEAD CHEEKS ETC 10 CM OR LESS","code_information":[{"code":"5100000141","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14040","type":"HCPCS"}],"standard_charges":[{"gross_charge":4443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJACENT TISS TRSFR FOREHEAD CHEEKS ETC 10.1 TO 30.0 CM","code_information":[{"code":"5100000142","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14041","type":"HCPCS"}],"standard_charges":[{"gross_charge":6745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJ TISS TRSFR EYELIDS NOSE EARS ETC 10 CM OR LESS","code_information":[{"code":"5100000143","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14060","type":"HCPCS"}],"standard_charges":[{"gross_charge":7196.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADJ TISS TRSFR ANY AREA 30.1 TO 60 CM","code_information":[{"code":"5100000145","type":"CDM"},{"code":"0510","type":"RC"},{"code":"14301","type":"HCPCS"}],"standard_charges":[{"gross_charge":6811.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PREP OF SITE EXC BURN SCAR EA ADDL 100 CM OR 1% OF BODY","code_information":[{"code":"5100000148","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15003","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PREP OF SITE EXC BURN SCAR 1ST 100 CM OR 1% OF BODY CHILD","code_information":[{"code":"5100000149","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15004","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PINCH GRAFT SING OR MULT SM ULCER ETC UP TO 2 CM","code_information":[{"code":"5100000151","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15050","type":"HCPCS"}],"standard_charges":[{"gross_charge":956.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLIT AUTOGRAFT TRUNK ETC 1ST 100 CM OR 1% OF BODY CHILD","code_information":[{"code":"5100000152","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15100","type":"HCPCS"}],"standard_charges":[{"gross_charge":4069.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SKIN GRAFT TRUNK ETC UP TO 100 CM 1ST 25 CM OR LESS","code_information":[{"code":"5100000159","type":"CDM"},{"code":"0510","type":"RC"},{"code":"C5271","type":"HCPCS"}],"standard_charges":[{"gross_charge":906.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SKIN GRAFT TRUNK ETC UP TO 100 CM EA ADDL 25 CM","code_information":[{"code":"5100000160","type":"CDM"},{"code":"0510","type":"RC"},{"code":"C5272","type":"HCPCS"}],"standard_charges":[{"gross_charge":511.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SKIN GRAFT TRUNK ETC OVER 100 CM 1ST 100 CM CHILD","code_information":[{"code":"5100000161","type":"CDM"},{"code":"0510","type":"RC"},{"code":"C5273","type":"HCPCS"}],"standard_charges":[{"gross_charge":5680.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SKIN GRAFT FACE ETC UP TO 100 1ST 25 CM OR LESS","code_information":[{"code":"5100000162","type":"CDM"},{"code":"0510","type":"RC"},{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"gross_charge":906.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INITIAL TREATMENT 1ST DEGREE BURN LOCAL TREATMENT","code_information":[{"code":"5100000175","type":"CDM"},{"code":"0510","type":"RC"},{"code":"16000","type":"HCPCS"}],"standard_charges":[{"gross_charge":427.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR AND OR DEBRIDE PRTL THKNS BURNS INIT OR SUBS SMALL","code_information":[{"code":"5100000176","type":"CDM"},{"code":"0510","type":"RC"},{"code":"16020","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR AND OR DEBRIDE PRTL THKNS BURNS INIT OR SUBS MED","code_information":[{"code":"5100000177","type":"CDM"},{"code":"0510","type":"RC"},{"code":"16025","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR AND OR DEBRIDE PRTL THKNS BURNS INIT OR SUBS LARGE","code_information":[{"code":"5100000178","type":"CDM"},{"code":"0510","type":"RC"},{"code":"16030","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR BEN LES NOT SKIN TAGS OR VASC PROLIF LES UP TO 14","code_information":[{"code":"5100000185","type":"CDM"},{"code":"0510","type":"RC"},{"code":"17110","type":"HCPCS"}],"standard_charges":[{"gross_charge":617.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMICAL CAUTERIZATION GRANULATION TISSUE","code_information":[{"code":"5100000187","type":"CDM"},{"code":"0510","type":"RC"},{"code":"17250","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PUNCTURE ASPIRATION CYST OF BREAST","code_information":[{"code":"5100000212","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19000","type":"HCPCS"}],"standard_charges":[{"gross_charge":980.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PUNCTURE ASPIRATION CYST OF BREAST EA ADDL","code_information":[{"code":"5100000213","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19001","type":"HCPCS"}],"standard_charges":[{"gross_charge":346.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MASTOTOMY W EXPLORATION OR DRAINAGE OF ABSCESS DEEP","code_information":[{"code":"5100000214","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19020","type":"HCPCS"}],"standard_charges":[{"gross_charge":3685.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC ONLY FOR MAMMARY DUCTOGRAM OR GALACTOGRAM","code_information":[{"code":"5100000215","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19030","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST NEEDLE CORE WO IMG GUIDANCE SEP PROC","code_information":[{"code":"5100000216","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19100","type":"HCPCS"}],"standard_charges":[{"gross_charge":1733.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST OPEN INCISIONAL","code_information":[{"code":"5100000217","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19101","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC CYST MAL TUMOR ABERRANT TISS 1 OR MORE LESIONS","code_information":[{"code":"5100000218","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19120","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXPLORATION OF PENETRATING WOUND SEP PROC EXTREMITY","code_information":[{"code":"5100000225","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20103","type":"HCPCS"}],"standard_charges":[{"gross_charge":1677.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY MUSCLE SUPERFICIAL","code_information":[{"code":"5100000226","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20200","type":"HCPCS"}],"standard_charges":[{"gross_charge":4713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY MUSCLE DEEP","code_information":[{"code":"5100000227","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20205","type":"HCPCS"}],"standard_charges":[{"gross_charge":8586.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY MUSCLE PERCUTANEOUS NEEDLE","code_information":[{"code":"5100000228","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20206","type":"HCPCS"}],"standard_charges":[{"gross_charge":3178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BONE TROCAR NEEDLE SUPERFICIAL","code_information":[{"code":"5100000229","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20220","type":"HCPCS"}],"standard_charges":[{"gross_charge":2500.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BONE TROCAR NEEDLE DEEP","code_information":[{"code":"5100000230","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20225","type":"HCPCS"}],"standard_charges":[{"gross_charge":4051.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SINUS TRACT DIAGNOSTIC SINOGRAM","code_information":[{"code":"5100000231","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20501","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ THERAPEUTIC CARPAL TUNNEL","code_information":[{"code":"5100000234","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20526","type":"HCPCS"}],"standard_charges":[{"gross_charge":917.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SING TENDON SHEATH LIGAMENT APONEUROSIS","code_information":[{"code":"5100000235","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20550","type":"HCPCS"}],"standard_charges":[{"gross_charge":575.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SING TENDON ORIGIN INSERTION","code_information":[{"code":"5100000236","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20551","type":"HCPCS"}],"standard_charges":[{"gross_charge":575.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SING MULT TRIGGER POINTS 1 OR 2 MUSCLES","code_information":[{"code":"5100000237","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20552","type":"HCPCS"}],"standard_charges":[{"gross_charge":409.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SING MULT TRIGGER POINTS 3 OR MORE MUSCLES","code_information":[{"code":"5100000238","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20553","type":"HCPCS"}],"standard_charges":[{"gross_charge":409.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROCENTESIS ASPIR AND OR INJ SMALL JOINT BURSA WO US","code_information":[{"code":"5100000239","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20600","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROCENTESIS ASPIR AND OR INJ INTERM JOINT BURSA WO US","code_information":[{"code":"5100000240","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20605","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROCENTESIS ASPIR AND OR INJ MAJOR JOINT BURSA WO US","code_information":[{"code":"5100000241","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20610","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASPIRATION AND OR INJ GANGLION CYST ANY LOCATION","code_information":[{"code":"5100000242","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20612","type":"HCPCS"}],"standard_charges":[{"gross_charge":613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM IMPLANT SUPERFICIAL SEP PROC","code_information":[{"code":"5100000243","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20670","type":"HCPCS"}],"standard_charges":[{"gross_charge":5031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM IMPLANT DEEP","code_information":[{"code":"5100000244","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20680","type":"HCPCS"}],"standard_charges":[{"gross_charge":8887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS FACE SCALP SUBC LESS THAN 2 CM","code_information":[{"code":"5100000248","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21011","type":"HCPCS"}],"standard_charges":[{"gross_charge":1844.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT NASAL FRACTURE  WO STABILIZATION","code_information":[{"code":"5100000254","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21315","type":"HCPCS"}],"standard_charges":[{"gross_charge":3038.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT NASAL FRACTURE W STABILIZATION","code_information":[{"code":"5100000255","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21320","type":"HCPCS"}],"standard_charges":[{"gross_charge":10070.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TEMPOROMANDIBULAR DISCL  INIT OR SUBS","code_information":[{"code":"5100000261","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21480","type":"HCPCS"}],"standard_charges":[{"gross_charge":1677.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY SOFT TISS NECK OR THORAX","code_information":[{"code":"5100000264","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21550","type":"HCPCS"}],"standard_charges":[{"gross_charge":2217.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS NECK OR THORAX SUBC LESS THAN 3 CM","code_information":[{"code":"5100000265","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21555","type":"HCPCS"}],"standard_charges":[{"gross_charge":3732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS NECK OR THORAX SUBF LESS THAN 5 CM","code_information":[{"code":"5100000266","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21556","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS BACK FLANK SUBC LESS THAN 3 CM","code_information":[{"code":"5100000268","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21930","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS BACK FLANK SUBC MORE THAN 3 CM","code_information":[{"code":"5100000269","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21931","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS BACK FLANK SUBF MORE THAN 5 CM","code_information":[{"code":"5100000270","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21933","type":"HCPCS"}],"standard_charges":[{"gross_charge":6613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS SHOULDER SUBC 3 CM OR MORE","code_information":[{"code":"5100000274","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23071","type":"HCPCS"}],"standard_charges":[{"gross_charge":5856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS SHOULDER SUBF 5 CM OR MORE","code_information":[{"code":"5100000275","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23073","type":"HCPCS"}],"standard_charges":[{"gross_charge":6745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC SHOULDER ARTHROGRAPHY OR ENHANCED CT MRI","code_information":[{"code":"5100000277","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23350","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT CLAVICULAR FRACTURE WO MANIP","code_information":[{"code":"5100000278","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23500","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT CLAVICULAR FRACTURE W MANIP","code_information":[{"code":"5100000279","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23505","type":"HCPCS"}],"standard_charges":[{"gross_charge":2419.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ACROMIOCLAVICULAR DISCL W MANIP","code_information":[{"code":"5100000282","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23545","type":"HCPCS"}],"standard_charges":[{"gross_charge":1923.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT SCAPULAR FRACTURE WO MANIP","code_information":[{"code":"5100000283","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23570","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT SCAPULAR FRACTURE W MANIP W WO SKEL TRAC","code_information":[{"code":"5100000284","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23575","type":"HCPCS"}],"standard_charges":[{"gross_charge":1736.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PROXI HUM FRACTURE WO MANIP","code_information":[{"code":"5100000285","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1586.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PROXI HUM FRACTURE W MANIP W WO SKEL TRAC","code_information":[{"code":"5100000286","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23605","type":"HCPCS"}],"standard_charges":[{"gross_charge":3678.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT GREATER HUM TUBER FRACTURE WO MANIP","code_information":[{"code":"5100000287","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23620","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT GREATER HUM TUBER FRACTURE W MANIP","code_information":[{"code":"5100000288","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23625","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT SHOULDER DISLC W MANIP WO ANES","code_information":[{"code":"5100000289","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23650","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT SHOULDER DISLC W MANIP W ANES","code_information":[{"code":"5100000290","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23655","type":"HCPCS"}],"standard_charges":[{"gross_charge":2223.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT SHOULDER DISLC W FRACTURE HUM TUBER W MANIP","code_information":[{"code":"5100000291","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23665","type":"HCPCS"}],"standard_charges":[{"gross_charge":3753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS UPPER ARM ELBOW SUBC 3 CM OR MORE","code_information":[{"code":"5100000293","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24071","type":"HCPCS"}],"standard_charges":[{"gross_charge":5585.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC ELBOW ARTHROGRAPHY","code_information":[{"code":"5100000295","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24220","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT HUM SHAFT FRACTURE WO MANIP","code_information":[{"code":"5100000296","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24500","type":"HCPCS"}],"standard_charges":[{"gross_charge":1627.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT HUM SHAFT FRACTURE W MANIP SKEL TRAC","code_information":[{"code":"5100000297","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24505","type":"HCPCS"}],"standard_charges":[{"gross_charge":1790.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT HUM CONDYLAR FRACTURE MEDIAL LATER W MANIP","code_information":[{"code":"5100000300","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24577","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TRTMT ELBOW DISLOC WO ANES","code_information":[{"code":"5100000301","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TRTMT ELBOW DISLOC W ANES","code_information":[{"code":"5100000302","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24605","type":"HCPCS"}],"standard_charges":[{"gross_charge":3979.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT MONTEGGIA FRACTURE DISLOC ELBOW W MANIP","code_information":[{"code":"5100000303","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24620","type":"HCPCS"}],"standard_charges":[{"gross_charge":3882.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT RDL HEAD SUBLXT CHILD ELBOW W MANIP","code_information":[{"code":"5100000304","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24640","type":"HCPCS"}],"standard_charges":[{"gross_charge":434.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT RADIAL HEAD NECK FRACTURE WO MANIP","code_information":[{"code":"5100000305","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24650","type":"HCPCS"}],"standard_charges":[{"gross_charge":673.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT RADIAL HEAD NECK FRACTURE  W MANIP","code_information":[{"code":"5100000306","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24655","type":"HCPCS"}],"standard_charges":[{"gross_charge":1788.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ULNAR FRACTURE PROXIMAL END W MANIP","code_information":[{"code":"5100000307","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24675","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS FOREARM OR WRIST SUBC 3 CM OR MORE","code_information":[{"code":"5100000309","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25071","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS FOREARM OR WRIST SUBC LESS THAN 3 CM","code_information":[{"code":"5100000311","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25075","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ WRIST ARTHROGRAPHY","code_information":[{"code":"5100000312","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25246","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT RADIAL SHAFT FRACTURE W MANIP","code_information":[{"code":"5100000316","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25505","type":"HCPCS"}],"standard_charges":[{"gross_charge":1784.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ULNAR SHAFT FRACTURE  WO MANIP","code_information":[{"code":"5100000317","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25530","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ULNAR SHAFT FRACTURE W MANIP","code_information":[{"code":"5100000318","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25535","type":"HCPCS"}],"standard_charges":[{"gross_charge":1632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT RADIAL AND ULNAR SHAFT FRACTURES WO MANIP","code_information":[{"code":"5100000319","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25560","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT RADIAL AND ULNAR SHAFT FRACTURES W MANIP","code_information":[{"code":"5100000320","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25565","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL RADIAL FRACTURE EPIPHYSL SEP WO MANIP","code_information":[{"code":"5100000321","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL RADIAL FRACTURE EPIPHYSL SEP W MANIP","code_information":[{"code":"5100000322","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25605","type":"HCPCS"}],"standard_charges":[{"gross_charge":1784.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT CARPAL SCAPHOID FRACTURE WO MANIP","code_information":[{"code":"5100000323","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25622","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT CARPAL BONE FRACTURE WO MANIP EA BONE","code_information":[{"code":"5100000324","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25630","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL RADIOULNAR DISL W MANIP","code_information":[{"code":"5100000327","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25675","type":"HCPCS"}],"standard_charges":[{"gross_charge":1659.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN FINGER ABSCESS SIMPLE","code_information":[{"code":"5100000329","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26010","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN FINGER ABSCESS COMPLICATED","code_information":[{"code":"5100000330","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26011","type":"HCPCS"}],"standard_charges":[{"gross_charge":2667.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENDON SHEATH INCISION","code_information":[{"code":"5100000332","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26055","type":"HCPCS"}],"standard_charges":[{"gross_charge":5085.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC LES TENDON SHTH JOINT CAPSULE HAND FINGER","code_information":[{"code":"5100000337","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26160","type":"HCPCS"}],"standard_charges":[{"gross_charge":5500.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP EXTENSOR TENDON FINGER PRI OR SEC WO GRAFT EA TEND","code_information":[{"code":"5100000341","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26418","type":"HCPCS"}],"standard_charges":[{"gross_charge":5684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL EXTENSOR TEND W WO PERC PINNING","code_information":[{"code":"5100000342","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26432","type":"HCPCS"}],"standard_charges":[{"gross_charge":7424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METACARPAL FRACTURE SINGLE WO MANIP EA BONE","code_information":[{"code":"5100000344","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26600","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METACARPAL FRACTURE SINGLE W MANIP EA BONE","code_information":[{"code":"5100000345","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26605","type":"HCPCS"}],"standard_charges":[{"gross_charge":3882.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METACARPAL DISL THUMB W MANIP","code_information":[{"code":"5100000346","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26641","type":"HCPCS"}],"standard_charges":[{"gross_charge":543.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC SKEL FIX METACARPAL FRACTURE DISL THUMB W MANIP","code_information":[{"code":"5100000347","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26650","type":"HCPCS"}],"standard_charges":[{"gross_charge":10075.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METACARPAL DISL NOT THUMB W MANIP EA WO ANS","code_information":[{"code":"5100000348","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26670","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METACARPAL DISL SING W MANIP WO ANS","code_information":[{"code":"5100000349","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26700","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PHLNGL FRACTURE PROX MID WO MANIP EACH","code_information":[{"code":"5100000350","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26720","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PHLNGL FRACTURE PROX MID PX W MANIP EA","code_information":[{"code":"5100000351","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26725","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ARTCLR FRACTURE METARCARPAL JOINT WO MANIP","code_information":[{"code":"5100000353","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26740","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ARTCLR FRACTURE METARCARPAL JOINT W MANIP","code_information":[{"code":"5100000354","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26742","type":"HCPCS"}],"standard_charges":[{"gross_charge":3753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL PHLNGL FRACTURE FING THMB WO MANIP EA","code_information":[{"code":"5100000355","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26750","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL PHLNGL FRACTURE FING THMB W MANIP EA","code_information":[{"code":"5100000356","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26755","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT INTRPHLNGL JOINT DISL SING W MANIP WO ANES","code_information":[{"code":"5100000359","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26770","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT INTRPHLNGL JOINT DISL SING W MANIP W ANES","code_information":[{"code":"5100000360","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26775","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPEN TREAT INTRPHLNGL JOINT DISL INCL INTER FIX SING","code_information":[{"code":"5100000361","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26785","type":"HCPCS"}],"standard_charges":[{"gross_charge":5110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC HIP ARTHROGRAPHY WO ANES","code_information":[{"code":"5100000364","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27093","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC HIP ARTHROGRAPHY W ANES","code_information":[{"code":"5100000365","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27095","type":"HCPCS"}],"standard_charges":[{"gross_charge":559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT GREATER TROCHANTERIC FRACTURE WO MANIP","code_information":[{"code":"5100000370","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27246","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT HIP DISL TRAUMATIC WO ANES","code_information":[{"code":"5100000371","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27250","type":"HCPCS"}],"standard_charges":[{"gross_charge":1632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT POST HIP ARTHRP DISL WO ANES","code_information":[{"code":"5100000372","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27265","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT POST HIP ARTHRP DISL W ANES","code_information":[{"code":"5100000373","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27266","type":"HCPCS"}],"standard_charges":[{"gross_charge":2712.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS THIGH KNEE SUBC 3 CM OR MORE","code_information":[{"code":"5100000375","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27337","type":"HCPCS"}],"standard_charges":[{"gross_charge":5856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FEM FRACTURE DSTAL END MEDIAL OR WO MANIP","code_information":[{"code":"5100000380","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27508","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PATELLAR FRACTURE WO MANIP","code_information":[{"code":"5100000381","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27520","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TIBIAL FRACTURE PROXIMAL WO MANIP","code_information":[{"code":"5100000382","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27530","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PATELLAR DISL WO ANES","code_information":[{"code":"5100000384","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27560","type":"HCPCS"}],"standard_charges":[{"gross_charge":1659.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PATELLAR DISL W ANES","code_information":[{"code":"5100000385","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27562","type":"HCPCS"}],"standard_charges":[{"gross_charge":1984.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP PRIMARY OPEN PERC RUPTURED ACHILLES TENDON","code_information":[{"code":"5100000386","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27650","type":"HCPCS"}],"standard_charges":[{"gross_charge":8543.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TIBIAL SHAFT FRACTURE WO MANIP","code_information":[{"code":"5100000387","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27750","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TIBIAL SHAFT FRACTURE W MANIP W WO SKEL TRACT","code_information":[{"code":"5100000388","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27752","type":"HCPCS"}],"standard_charges":[{"gross_charge":2738.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT MEDIAL MALLS FRACTURE W MANIP W WO SKEL TRACT","code_information":[{"code":"5100000390","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27762","type":"HCPCS"}],"standard_charges":[{"gross_charge":2324.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PROX FIBULA SHAFT FRACTURE W MANIP","code_information":[{"code":"5100000393","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27781","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL FIBULAR FRACTURE LAT MALLS WO MANIP","code_information":[{"code":"5100000394","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27786","type":"HCPCS"}],"standard_charges":[{"gross_charge":1627.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT DISTAL FIBULAR FRACTURE LAT MALLS W MANIP","code_information":[{"code":"5100000395","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27788","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT BIMALLEOLAR ANKLE FRACTURE WO MANIP","code_information":[{"code":"5100000396","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27808","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT BIMALLEOLAR ANKLE FRACTURE W MANIP","code_information":[{"code":"5100000397","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27810","type":"HCPCS"}],"standard_charges":[{"gross_charge":1670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TRIMALLEOLAR ANKLE FRACTURE WO MANIP","code_information":[{"code":"5100000398","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27816","type":"HCPCS"}],"standard_charges":[{"gross_charge":1627.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TRIMALLEOLAR ANKLE FRACTURE W MANIP","code_information":[{"code":"5100000399","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27818","type":"HCPCS"}],"standard_charges":[{"gross_charge":1784.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FRACTURE WEIGHT ARTCLR DISTL TIBIA WO MANIP","code_information":[{"code":"5100000400","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27824","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FRACTURE WEIGHT ARTCLR DSTL TIB W SKEL TRA OR ANE","code_information":[{"code":"5100000401","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27825","type":"HCPCS"}],"standard_charges":[{"gross_charge":2277.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT PROX TIBFIB JOINT DISL WO ANES","code_information":[{"code":"5100000402","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27830","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ANKLE DISL WO ANES","code_information":[{"code":"5100000403","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27840","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ANKLE DISL REQ ANES W WO PERC SKEL FIX","code_information":[{"code":"5100000404","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27842","type":"HCPCS"}],"standard_charges":[{"gross_charge":4755.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM FOREIGN BODY FOOT SUBC","code_information":[{"code":"5100000409","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28190","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TENOTOMY OPEN EXTENSOR FOOT OR TOE EA TENDON","code_information":[{"code":"5100000411","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28234","type":"HCPCS"}],"standard_charges":[{"gross_charge":4134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CORRECTION HAMMERTOE PART OR TOTAL","code_information":[{"code":"5100000412","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28285","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT CALCANEAL FRACTURE WO MANIP","code_information":[{"code":"5100000413","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28400","type":"HCPCS"}],"standard_charges":[{"gross_charge":1923.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TALUS FRACTURE WO MANIP","code_information":[{"code":"5100000414","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28430","type":"HCPCS"}],"standard_charges":[{"gross_charge":1227.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METATARSAL FRACTURE WO MANIP","code_information":[{"code":"5100000416","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28470","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METATARSAL FRACTURE W MANIP","code_information":[{"code":"5100000417","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28475","type":"HCPCS"}],"standard_charges":[{"gross_charge":720.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FRACTURE GREAT TOE PHALX OR PHALG WO MANIP","code_information":[{"code":"5100000418","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28490","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FRACTURE GREAT TOE PHALX OR PHALG  W MANIP","code_information":[{"code":"5100000419","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28495","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FRACTURE PHLX PHLG NOT GREAT TOE WO MANIP","code_information":[{"code":"5100000420","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28510","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT FRACTURE PHLX PHLG NOT GREAT TOE W MANIP","code_information":[{"code":"5100000421","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28515","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT TARSOMETATARSAL JOINT DISL WO ANES","code_information":[{"code":"5100000423","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28600","type":"HCPCS"}],"standard_charges":[{"gross_charge":698.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT INTERPHALANGEAL JOINT DISL WO ANES","code_information":[{"code":"5100000424","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28660","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL CAST SHOULDER HAND LONG ARM","code_information":[{"code":"5100000426","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29065","type":"HCPCS"}],"standard_charges":[{"gross_charge":608.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL CAST ELBOW FINGER SHORT ARM","code_information":[{"code":"5100000427","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29075","type":"HCPCS"}],"standard_charges":[{"gross_charge":573.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL CAST HAND AND LOWER FOREARM GAUNTLET","code_information":[{"code":"5100000428","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29085","type":"HCPCS"}],"standard_charges":[{"gross_charge":573.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL LONG ARM SPLINT SHOULDER HAND","code_information":[{"code":"5100000429","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29105","type":"HCPCS"}],"standard_charges":[{"gross_charge":350.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SHORT ARM SPLINT FOREARM HAND STATIC","code_information":[{"code":"5100000430","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29125","type":"HCPCS"}],"standard_charges":[{"gross_charge":393.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SHORT ARM SPLINT DYNAMIC","code_information":[{"code":"5100000431","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29126","type":"HCPCS"}],"standard_charges":[{"gross_charge":573.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL FINGER SPLINT STATIC","code_information":[{"code":"5100000432","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29130","type":"HCPCS"}],"standard_charges":[{"gross_charge":304.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL LONG LEG CAST THIGH TOE","code_information":[{"code":"5100000433","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29345","type":"HCPCS"}],"standard_charges":[{"gross_charge":741.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SHORT LEG CAST BELOW KNEE TOE","code_information":[{"code":"5100000435","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29405","type":"HCPCS"}],"standard_charges":[{"gross_charge":849.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL RIGID TOTAL CONTACT LEG CAST","code_information":[{"code":"5100000438","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29445","type":"HCPCS"}],"standard_charges":[{"gross_charge":621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL LONG LEG SPLINT THIGH ANKLE TOES","code_information":[{"code":"5100000439","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29505","type":"HCPCS"}],"standard_charges":[{"gross_charge":346.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SHORT LEG SPLINT CALF FOOT","code_information":[{"code":"5100000440","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29515","type":"HCPCS"}],"standard_charges":[{"gross_charge":346.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING KNEE","code_information":[{"code":"5100000442","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29530","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING ANKLE AND OR FOOT","code_information":[{"code":"5100000443","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29540","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING TOES","code_information":[{"code":"5100000444","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29550","type":"HCPCS"}],"standard_charges":[{"gross_charge":158.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING UNNA BOOT","code_information":[{"code":"5100000445","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29580","type":"HCPCS"}],"standard_charges":[{"gross_charge":336.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL MLTLAYR COMPRES LEG BELOW KNEE INC ANK AND FOOT","code_information":[{"code":"5100000446","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29581","type":"HCPCS"}],"standard_charges":[{"gross_charge":409.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN ABSCESS HEMATOMA NASAL SEPTUM","code_information":[{"code":"5100000449","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30020","type":"HCPCS"}],"standard_charges":[{"gross_charge":1364.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM FOREIGN BODY INTRANASAL OFFICE TYPE PROC","code_information":[{"code":"5100000456","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30300","type":"HCPCS"}],"standard_charges":[{"gross_charge":427.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CTRL NASAL HEMORRHAGE ANTERIOR SIMPLE","code_information":[{"code":"5100000459","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30901","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CTRL NASAL HEMORRHAGE ANTERIOR COMPLEX","code_information":[{"code":"5100000460","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30903","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CTRL NASAL HEMORRHAGE POST NASAL PACKS AND CAUTERY INIT","code_information":[{"code":"5100000461","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30905","type":"HCPCS"}],"standard_charges":[{"gross_charge":1670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CTRL NASAL HEMORRHAGE POST NASAL PACKS AND CAUTERY SUBS","code_information":[{"code":"5100000462","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30906","type":"HCPCS"}],"standard_charges":[{"gross_charge":1950.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NASAL ENDOSCOPY DIAGNOSTIC UNI OR BIL SEP PROC","code_information":[{"code":"5100000463","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31231","type":"HCPCS"}],"standard_charges":[{"gross_charge":589.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTUBATION ENDOTRACHAEL EMERGENCY PROC","code_information":[{"code":"5100000467","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31500","type":"HCPCS"}],"standard_charges":[{"gross_charge":546.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACTION","code_information":[{"code":"5100000468","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31502","type":"HCPCS"}],"standard_charges":[{"gross_charge":496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LARYNG INDIRECT DIAGNOSTIC SEPARATE PROC","code_information":[{"code":"5100000469","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31505","type":"HCPCS"}],"standard_charges":[{"gross_charge":588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LARYNG W WO TRACTIONHEOSCOPY DIAG NOT NEWBORN","code_information":[{"code":"5100000472","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31525","type":"HCPCS"}],"standard_charges":[{"gross_charge":2648.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LARYNG FLEXIBLE FIBEROPTIC DIAGNOSTIC","code_information":[{"code":"5100000475","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31575","type":"HCPCS"}],"standard_charges":[{"gross_charge":570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LARYNG FLEXIBLE FIBEROPTIC W REM FOREIGN BODY","code_information":[{"code":"5100000477","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31577","type":"HCPCS"}],"standard_charges":[{"gross_charge":1525.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRACHEOSTOMY PLANNED SEPARATE PROC","code_information":[{"code":"5100000480","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31600","type":"HCPCS"}],"standard_charges":[{"gross_charge":5342.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE DX W CELL WASHING SEP PROC","code_information":[{"code":"5100000485","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31622","type":"HCPCS"}],"standard_charges":[{"gross_charge":3342.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W BRUSH OR PROT BRUSH","code_information":[{"code":"5100000486","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31623","type":"HCPCS"}],"standard_charges":[{"gross_charge":2686.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W BRNCL ALVEOLAR LAVAGE","code_information":[{"code":"5100000487","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31624","type":"HCPCS"}],"standard_charges":[{"gross_charge":2497.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W BRONC ENDO BIOPSY 1 OR MORE","code_information":[{"code":"5100000488","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31625","type":"HCPCS"}],"standard_charges":[{"gross_charge":5229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W IMAGE GUID NAVIGATION","code_information":[{"code":"5100000490","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31627","type":"HCPCS"}],"standard_charges":[{"gross_charge":281.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W TRNSBRN LUNG BIOPSY 1ST LOBE","code_information":[{"code":"5100000491","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31628","type":"HCPCS"}],"standard_charges":[{"gross_charge":5229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W TRNSBRN NDL ASP BIOPSY","code_information":[{"code":"5100000492","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31629","type":"HCPCS"}],"standard_charges":[{"gross_charge":13135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE W TRACHEAL BRONC OR CLOSED","code_information":[{"code":"5100000493","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31630","type":"HCPCS"}],"standard_charges":[{"gross_charge":5237.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE FOR THER ASP TRACT TREE INIT","code_information":[{"code":"5100000501","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31645","type":"HCPCS"}],"standard_charges":[{"gross_charge":2497.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIG OR FLEX W GUIDE FOR THER ASPTRACT TREE SUBS","code_information":[{"code":"5100000502","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31646","type":"HCPCS"}],"standard_charges":[{"gross_charge":2497.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH THERMOPLASTY 1 LOBE","code_information":[{"code":"5100000504","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31660","type":"HCPCS"}],"standard_charges":[{"gross_charge":13062.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH THERMOPLASTY 2 OR MORE LOBES","code_information":[{"code":"5100000505","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31661","type":"HCPCS"}],"standard_charges":[{"gross_charge":21494.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY PLEURA PERC NEEDLE","code_information":[{"code":"5100000508","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32400","type":"HCPCS"}],"standard_charges":[{"gross_charge":1763.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT OF NDL INDWELLING TUNNELED PLEURAL CATH W CUFF","code_information":[{"code":"5100000510","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32550","type":"HCPCS"}],"standard_charges":[{"gross_charge":5621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TUBE THORACOSTOMY INCL CONNECT TO DRAIN SYSTEM","code_information":[{"code":"5100000511","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32551","type":"HCPCS"}],"standard_charges":[{"gross_charge":3912.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM INDWELLING TUNNELED PLEURAL CATH W CUFF","code_information":[{"code":"5100000512","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32552","type":"HCPCS"}],"standard_charges":[{"gross_charge":1627.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACEMENT INTRSTL DEV RAD GUIDE PERC INTRATHOR 1 OR MORE","code_information":[{"code":"5100000513","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32553","type":"HCPCS"}],"standard_charges":[{"gross_charge":4875.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORAC NEEDLE OR CATH OF PLEURAL SPACE WO IMAGING","code_information":[{"code":"5100000514","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32554","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORAC NEEDLE OR CATH OR PLEURAL SPACE W IMAGING","code_information":[{"code":"5100000515","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32555","type":"HCPCS"}],"standard_charges":[{"gross_charge":1787.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC DRAIN OR PLEURAL SPACE W INSERT CATH WO IMAGING","code_information":[{"code":"5100000516","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32556","type":"HCPCS"}],"standard_charges":[{"gross_charge":2001.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC DRAIN OR PLEURAL SPACE W INSERT CATH W IMAGING","code_information":[{"code":"5100000517","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32557","type":"HCPCS"}],"standard_charges":[{"gross_charge":2101.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSTILL VIA CHEST TUBE OR CATH OF AGENT FOR PLEURODESIS","code_information":[{"code":"5100000518","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32560","type":"HCPCS"}],"standard_charges":[{"gross_charge":2203.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSTILL VIA CHEST TUBE OR CATH AGENT FOR FIBRINLOYSIS 1ST DAY","code_information":[{"code":"5100000519","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32561","type":"HCPCS"}],"standard_charges":[{"gross_charge":1742.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SCLEROSING SOLUTION SINGLE VEIN","code_information":[{"code":"5100000522","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36470","type":"HCPCS"}],"standard_charges":[{"gross_charge":943.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG","code_information":[{"code":"5100000523","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36471","type":"HCPCS"}],"standard_charges":[{"gross_charge":920.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THER APHERESIS FOR PLASMA PHERESIS","code_information":[{"code":"5100000524","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36514","type":"HCPCS"}],"standard_charges":[{"gross_charge":5090.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT NON TUN CENTRAL VENOUS CATH OVER 5 YEARS OLD","code_information":[{"code":"5100000525","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36556","type":"HCPCS"}],"standard_charges":[{"gross_charge":2548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE COMPL OF PERPH PICC LINE WO SUBQ PORT OR PUMP","code_information":[{"code":"5100000529","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36584","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF TUNNEL CVC WO SUBC PORT OR PUMP","code_information":[{"code":"5100000530","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36589","type":"HCPCS"}],"standard_charges":[{"gross_charge":2403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF TUNNEL CTR VAD W SUBC PORT CENTR OR PERIPH INS","code_information":[{"code":"5100000531","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36590","type":"HCPCS"}],"standard_charges":[{"gross_charge":3469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLLECT BLOOD FROM COMPL IMPLANTABLE VEN ACCESS DEV","code_information":[{"code":"5100000532","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36591","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DECLOTTING BY THRMBLYTIC AGENT OF IMPLANT VAD OR CATH","code_information":[{"code":"5100000533","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36593","type":"HCPCS"}],"standard_charges":[{"gross_charge":593.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPOS OF PREVIOUSLY PLACED CVC UNDER FLUOR GUIDANCE","code_information":[{"code":"5100000534","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36597","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONTR INJ RAD EVAL OF CVA DEV INC FLURO W DOC AND REPT","code_information":[{"code":"5100000535","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36598","type":"HCPCS"}],"standard_charges":[{"gross_charge":600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS","code_information":[{"code":"5100000536","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36600","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION","code_information":[{"code":"5100000537","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36680","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIGATION OR BIOPSY OF TEMPORAL ARTERY","code_information":[{"code":"5100000538","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37609","type":"HCPCS"}],"standard_charges":[{"gross_charge":3844.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE MARROW ASPIRATION ONLY","code_information":[{"code":"5100000541","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38220","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE MARROW BIOPSY NEEDLE OR TROCAR","code_information":[{"code":"5100000542","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38221","type":"HCPCS"}],"standard_charges":[{"gross_charge":2500.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OR EXC OF LYMPH NODE OPEN SUPERFICIAL","code_information":[{"code":"5100000543","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38500","type":"HCPCS"}],"standard_charges":[{"gross_charge":3972.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OR EXC OF LYMPH NODE BY NEEDLE SUPERFICIAL","code_information":[{"code":"5100000544","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38505","type":"HCPCS"}],"standard_charges":[{"gross_charge":3972.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC RADIOACTIVE TRACER FOR ID OF SENTINEL NODE","code_information":[{"code":"5100000545","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38792","type":"HCPCS"}],"standard_charges":[{"gross_charge":638.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP LIP FULL THICKNESS VERMILION ONLY","code_information":[{"code":"5100000547","type":"CDM"},{"code":"0510","type":"RC"},{"code":"40650","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP LIP FULL THICKNESS UP TO HALF VERTICAL HGHT","code_information":[{"code":"5100000548","type":"CDM"},{"code":"0510","type":"RC"},{"code":"40652","type":"HCPCS"}],"standard_charges":[{"gross_charge":5802.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP LIP FULL THICKNESS MORE THAN HALF VERT HGHT OR COMP","code_information":[{"code":"5100000549","type":"CDM"},{"code":"0510","type":"RC"},{"code":"40654","type":"HCPCS"}],"standard_charges":[{"gross_charge":6054.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN ABSCESS CYST OR HEMATOMA VESTIBULE OF MOUTH SIMP","code_information":[{"code":"5100000550","type":"CDM"},{"code":"0510","type":"RC"},{"code":"40800","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSURE OF LACERATION VESTIBULE OF MOUTH 2.5 CM OR LESS","code_information":[{"code":"5100000556","type":"CDM"},{"code":"0510","type":"RC"},{"code":"40830","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP LAC TO FLR OF MOUTH OR ANTER TONG 2.5 CM OR LESS","code_information":[{"code":"5100000563","type":"CDM"},{"code":"0510","type":"RC"},{"code":"41250","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN OF ABSCESS CYST HEMATOMA FROM DENTAL STRUCT","code_information":[{"code":"5100000564","type":"CDM"},{"code":"0510","type":"RC"},{"code":"41800","type":"HCPCS"}],"standard_charges":[{"gross_charge":1640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY SALIVARY GLAND NEEDLE","code_information":[{"code":"5100000570","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42400","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN ABSCESS PERITONSILLAR","code_information":[{"code":"5100000573","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1659.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE ESOPH BY UNGUIDED SOUND OR BOUGIE ONE OR MORE","code_information":[{"code":"5100000576","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43450","type":"HCPCS"}],"standard_charges":[{"gross_charge":2682.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE ESOPH OVER GUIDE WIRE","code_information":[{"code":"5100000577","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43453","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSCOPIC MUCOSAL RESECTION","code_information":[{"code":"5100000578","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43499","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NASO OR ORO GAST TUBE PLACE W PHYS W FLUOR GUIDE W RPT","code_information":[{"code":"5100000580","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43752","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPOS NASO OR ORO GASTRIC FEEDING TUBE THRU DUODENUM","code_information":[{"code":"5100000582","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43761","type":"HCPCS"}],"standard_charges":[{"gross_charge":1318.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LAP BAND ADJUSTMENT","code_information":[{"code":"5100000584","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1926.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL INTEST ENDO OR ENTESCPY W REM LES ETC W SNARE","code_information":[{"code":"5100000585","type":"CDM"},{"code":"0510","type":"RC"},{"code":"44364","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL INTEST ENDO OR ENTRSCPY W REM LES W FORCEP CAUT","code_information":[{"code":"5100000586","type":"CDM"},{"code":"0510","type":"RC"},{"code":"44365","type":"HCPCS"}],"standard_charges":[{"gross_charge":5961.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSC EVAL SMALL INTEST POUCH W SPEC COLL WHEN PRFMD","code_information":[{"code":"5100000587","type":"CDM"},{"code":"0510","type":"RC"},{"code":"44385","type":"HCPCS"}],"standard_charges":[{"gross_charge":2266.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSC EVAL SMALL INTEST POUCH W BX SGL OR MUTL","code_information":[{"code":"5100000588","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44386","type":"HCPCS"}],"standard_charges":[{"gross_charge":2070.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO LONG GI TUBE SEPARATE PROCEDURE","code_information":[{"code":"5100000589","type":"CDM"},{"code":"0510","type":"RC"},{"code":"44500","type":"HCPCS"}],"standard_charges":[{"gross_charge":3340.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANORECTAL EXAM SURG REQ GEN ANES","code_information":[{"code":"5100000591","type":"CDM"},{"code":"0510","type":"RC"},{"code":"45990","type":"HCPCS"}],"standard_charges":[{"gross_charge":3678.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTR LESION ANUS SIMPLE SURG EXC","code_information":[{"code":"5100000597","type":"CDM"},{"code":"0510","type":"RC"},{"code":"46922","type":"HCPCS"}],"standard_charges":[{"gross_charge":3080.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY LIVER PERN NEEDLE","code_information":[{"code":"5100000600","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABLATION ONE OR MORE LIVER TUMORS PERC","code_information":[{"code":"5100000601","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47382","type":"HCPCS"}],"standard_charges":[{"gross_charge":9524.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHOLECYSTOSTOMY PERC W IMAGE AND CATH PLACEMENT","code_information":[{"code":"5100000602","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47490","type":"HCPCS"}],"standard_charges":[{"gross_charge":6600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY PANCREAS PERC NEEDLE","code_information":[{"code":"5100000615","type":"CDM"},{"code":"0510","type":"RC"},{"code":"48102","type":"HCPCS"}],"standard_charges":[{"gross_charge":1763.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABDOM PARACENTESIS DIAG OR THER WO IMG GUIDE","code_information":[{"code":"5100000616","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49082","type":"HCPCS"}],"standard_charges":[{"gross_charge":2054.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABDOM PARACENTESIS DIAG OR THER W IMG GUIDE","code_information":[{"code":"5100000617","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49083","type":"HCPCS"}],"standard_charges":[{"gross_charge":1616.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY ABDOM OR RETROPERITONEAL MASS PERC NEEDLE","code_information":[{"code":"5100000619","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49180","type":"HCPCS"}],"standard_charges":[{"gross_charge":1488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMAGE GUIDED FLUID COLL DRAIN CATH VISC PERC","code_information":[{"code":"5100000620","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49405","type":"HCPCS"}],"standard_charges":[{"gross_charge":4442.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMAGE GUIDED FLUID COLL DRAIN CATH PERIT OR RETRO PERC","code_information":[{"code":"5100000621","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49406","type":"HCPCS"}],"standard_charges":[{"gross_charge":4442.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMAGE GUIDED FLUID COLL DRAIN CATH PERIT OR RETRO TRNS OR VAG","code_information":[{"code":"5100000622","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49407","type":"HCPCS"}],"standard_charges":[{"gross_charge":2184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACEMENT INSTERTIAL DEV PLACE RADIATION THER SING OR MULT","code_information":[{"code":"5100000623","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49411","type":"HCPCS"}],"standard_charges":[{"gross_charge":12627.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT INTRAPERITONEAL CATH W IMG GUIDANCE","code_information":[{"code":"5100000624","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49418","type":"HCPCS"}],"standard_charges":[{"gross_charge":8560.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL TUNNELED INTRAPERITONEAL CATH","code_information":[{"code":"5100000625","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49422","type":"HCPCS"}],"standard_charges":[{"gross_charge":9774.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXCHANGE ABSC OR CST DRAIN CATH RAD W IMG GUIDANCE","code_information":[{"code":"5100000626","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49423","type":"HCPCS"}],"standard_charges":[{"gross_charge":3968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ CONTR ASSMT ABSC CST VIA DRAIN CATH OR TUBE SEP PROC","code_information":[{"code":"5100000627","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49424","type":"HCPCS"}],"standard_charges":[{"gross_charge":1520.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT GASTRSTOMY TUBE PERC INC FLUOR GUIDE AND CONTR","code_information":[{"code":"5100000628","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49440","type":"HCPCS"}],"standard_charges":[{"gross_charge":7740.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONVERT GASTROSTOMY GASTRO JEJUNOSTOMY TUBE PERC","code_information":[{"code":"5100000629","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49446","type":"HCPCS"}],"standard_charges":[{"gross_charge":5691.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE GASTROSTOMY OR CECOSTOMY TUBE PERC","code_information":[{"code":"5100000630","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE DUODENSTMY OR JEJUNOSTOMY TUBE PERC FLUOR GUIDE","code_information":[{"code":"5100000631","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49451","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE GASTRO JEJUNOSTOMY TUBE PERC","code_information":[{"code":"5100000632","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49452","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ CONTR PERC RADIOLOGIC EVAL GI TUBE","code_information":[{"code":"5100000634","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49465","type":"HCPCS"}],"standard_charges":[{"gross_charge":545.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC NEPHROSTOLITHTMY PYELOSTOLITHTMY  UP TO 2 CM","code_information":[{"code":"5100000635","type":"CDM"},{"code":"0510","type":"RC"},{"code":"50080","type":"HCPCS"}],"standard_charges":[{"gross_charge":7287.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ CSTOGRAPY OR VOIDING URETHROCSTOGRAPY","code_information":[{"code":"5100000637","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1299.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ RETROGRADE URETHROCSTOGRAPY","code_information":[{"code":"5100000638","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51610","type":"HCPCS"}],"standard_charges":[{"gross_charge":1165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BLADDER IRRIGATION SIMP LAVAGE AND OR INSTL","code_information":[{"code":"5100000639","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51700","type":"HCPCS"}],"standard_charges":[{"gross_charge":570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT NON NDWELLG BLADDER CATH","code_information":[{"code":"5100000640","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51701","type":"HCPCS"}],"standard_charges":[{"gross_charge":389.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT TEMP NDWELLG BLADDER CATH SIMPLE","code_information":[{"code":"5100000641","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51702","type":"HCPCS"}],"standard_charges":[{"gross_charge":389.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT TEMP NDWELLG BLADDER CATH COMPLICATED","code_information":[{"code":"5100000642","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51703","type":"HCPCS"}],"standard_charges":[{"gross_charge":415.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHANGE CYSTOSTOMY TUBE SIMPLE","code_information":[{"code":"5100000643","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51705","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHANGE CYSTOSTOMY TUBE COMPLICATED","code_information":[{"code":"5100000644","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51710","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT","code_information":[{"code":"5100000646","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51720","type":"HCPCS"}],"standard_charges":[{"gross_charge":1000.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MEASURE OF POST VOIDING RESIDUAL URINE AND OR BLADDER CAP","code_information":[{"code":"5100000655","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51798","type":"HCPCS"}],"standard_charges":[{"gross_charge":265.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTOURETHROSCOPY","code_information":[{"code":"5100000656","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52000","type":"HCPCS"}],"standard_charges":[{"gross_charge":2207.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO BLADDER W URETERAL CATHIZATION","code_information":[{"code":"5100000658","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52005","type":"HCPCS"}],"standard_charges":[{"gross_charge":5076.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO W FULG AND OR RESEC OF MEDIUM BLADDER TUMORS","code_information":[{"code":"5100000663","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52235","type":"HCPCS"}],"standard_charges":[{"gross_charge":10709.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO CALIBRATION AND OR DILAT URTL STRIX OR STENOSIS","code_information":[{"code":"5100000665","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52281","type":"HCPCS"}],"standard_charges":[{"gross_charge":5060.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO W SIMP REM STONE STENT OR FOREIGN BODY","code_information":[{"code":"5100000667","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52310","type":"HCPCS"}],"standard_charges":[{"gross_charge":5148.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO W COMPLEX REM STONE STENT OR FOREIGN BODY","code_information":[{"code":"5100000668","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52315","type":"HCPCS"}],"standard_charges":[{"gross_charge":6361.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LITHOLAPAXY SIMP OR SM LESS THAN 2.5 CM","code_information":[{"code":"5100000669","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52317","type":"HCPCS"}],"standard_charges":[{"gross_charge":10709.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO W INSERT URETERAL STENT","code_information":[{"code":"5100000672","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52332","type":"HCPCS"}],"standard_charges":[{"gross_charge":10709.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN OF SKINENES GLAND ABSCESS OR CYST","code_information":[{"code":"5100000678","type":"CDM"},{"code":"0510","type":"RC"},{"code":"53060","type":"HCPCS"}],"standard_charges":[{"gross_charge":4028.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE URETHRAL STRICT DILATOR MALE INITIAL","code_information":[{"code":"5100000680","type":"CDM"},{"code":"0510","type":"RC"},{"code":"53600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE URETHRAL STRICT DILATOR MALE SUBS","code_information":[{"code":"5100000681","type":"CDM"},{"code":"0510","type":"RC"},{"code":"53601","type":"HCPCS"}],"standard_charges":[{"gross_charge":496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE FEMALE URETHRA W SUPPOSITORY AND OR INSTL INITIAL","code_information":[{"code":"5100000682","type":"CDM"},{"code":"0510","type":"RC"},{"code":"53660","type":"HCPCS"}],"standard_charges":[{"gross_charge":474.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATE W BALLOON URETHRA WO STENT","code_information":[{"code":"5100000684","type":"CDM"},{"code":"0510","type":"RC"},{"code":"53899","type":"HCPCS"}],"standard_charges":[{"gross_charge":756.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OF PENIS SEP PROC","code_information":[{"code":"5100000692","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54100","type":"HCPCS"}],"standard_charges":[{"gross_charge":5031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CIRCUMCISION W CLAMP OR OTH DEV W BLOCK","code_information":[{"code":"5100000693","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54150","type":"HCPCS"}],"standard_charges":[{"gross_charge":3234.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PEYRONIE DISEASE","code_information":[{"code":"5100000694","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54200","type":"HCPCS"}],"standard_charges":[{"gross_charge":1270.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IRRIGATION CORPORA CAVERNOSA PRIAPISM","code_information":[{"code":"5100000695","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54220","type":"HCPCS"}],"standard_charges":[{"gross_charge":1621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ CORPORA CAVERNOSA W PHARMACOLOGIC AGNT","code_information":[{"code":"5100000696","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54235","type":"HCPCS"}],"standard_charges":[{"gross_charge":618.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN EPIDIDYMIS TESTIS AND OR SCROTAL SPACE","code_information":[{"code":"5100000697","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54700","type":"HCPCS"}],"standard_charges":[{"gross_charge":3771.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PUNCTURE ASPIR HYDROCELE TUNICA VAGIS W WO INJ MED","code_information":[{"code":"5100000698","type":"CDM"},{"code":"0510","type":"RC"},{"code":"55000","type":"HCPCS"}],"standard_charges":[{"gross_charge":2185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAINAGE SCROTAL WALL ABSCESS","code_information":[{"code":"5100000699","type":"CDM"},{"code":"0510","type":"RC"},{"code":"55100","type":"HCPCS"}],"standard_charges":[{"gross_charge":1733.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN VULVA PERINEAL ABSCESS","code_information":[{"code":"5100000704","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN OF BARTHOLINS GLAND ABSCESS","code_information":[{"code":"5100000705","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56420","type":"HCPCS"}],"standard_charges":[{"gross_charge":1581.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTR LESIONS VULVA SIMPLE","code_information":[{"code":"5100000706","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56501","type":"HCPCS"}],"standard_charges":[{"gross_charge":2936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTR LESIONS VULVA EXTENSIVE","code_information":[{"code":"5100000707","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56515","type":"HCPCS"}],"standard_charges":[{"gross_charge":7690.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY VULVA PERINEUM 1 LESION SPX","code_information":[{"code":"5100000708","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56605","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY VULVA PERINEUM EA ADD LESION","code_information":[{"code":"5100000709","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56606","type":"HCPCS"}],"standard_charges":[{"gross_charge":320.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY VULVA","code_information":[{"code":"5100000711","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56820","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY VULVA W BIOPSY","code_information":[{"code":"5100000712","type":"CDM"},{"code":"0510","type":"RC"},{"code":"56821","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTR VAGINAL LESIONS SIMPLE","code_information":[{"code":"5100000713","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57061","type":"HCPCS"}],"standard_charges":[{"gross_charge":3374.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OF VAGINAL MUCOSA SIMP SEP PROC","code_information":[{"code":"5100000714","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57100","type":"HCPCS"}],"standard_charges":[{"gross_charge":1659.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT VAGINAL RADIATION DEV FOR CLIN BRACHYTHERAPY","code_information":[{"code":"5100000716","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57156","type":"HCPCS"}],"standard_charges":[{"gross_charge":1792.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FITTING AND INSERT PESSARY OR OTH INTRAVAGINAL SUPPORT DEV","code_information":[{"code":"5100000717","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57160","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO ANY HEMOSTATIC AGENT PACK VAG HEMRRG SPX","code_information":[{"code":"5100000719","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57180","type":"HCPCS"}],"standard_charges":[{"gross_charge":818.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PELVIC EXAMINATION W ANES OTHER THAN LOCAL","code_information":[{"code":"5100000720","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57410","type":"HCPCS"}],"standard_charges":[{"gross_charge":9873.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY ENTIRE VAGINA W CERVIX IF PRESENT","code_information":[{"code":"5100000721","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57420","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY ENTIRE VAGINA OR CERVIX W BIOPSYS","code_information":[{"code":"5100000722","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57421","type":"HCPCS"}],"standard_charges":[{"gross_charge":918.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY CERVIX UPPER OR ADJCNT VAGINA","code_information":[{"code":"5100000723","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57452","type":"HCPCS"}],"standard_charges":[{"gross_charge":580.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY INC VAG  W BIOPSY OF CERVIX AND ENDOCERVICAL","code_information":[{"code":"5100000724","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57454","type":"HCPCS"}],"standard_charges":[{"gross_charge":1266.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY INC VAG CERVIX BIOPSY","code_information":[{"code":"5100000725","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57455","type":"HCPCS"}],"standard_charges":[{"gross_charge":1328.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY INC VAG CERVIX BIOPSY AND ENDOCERVICAL CURET","code_information":[{"code":"5100000726","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57456","type":"HCPCS"}],"standard_charges":[{"gross_charge":1364.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY CERVIX UPPER OR ADJ VAG LOOP ELTRD BIOPSY CERV","code_information":[{"code":"5100000727","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57460","type":"HCPCS"}],"standard_charges":[{"gross_charge":4097.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLPOSCOPY CERVIX UPPER OR ADJ VAG ELTRD CONIZATION CERV","code_information":[{"code":"5100000728","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57461","type":"HCPCS"}],"standard_charges":[{"gross_charge":7801.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY CERVIX SINGLE MULT EXCIS OF LESIONS SEP PROC","code_information":[{"code":"5100000729","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57500","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOCERVICAL CURETTAGE W DILATION AND CURETTAGE","code_information":[{"code":"5100000730","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57505","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONIZATION CERVIX W WO DILATION AND CURRETAGE LOOP EXC","code_information":[{"code":"5100000731","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57522","type":"HCPCS"}],"standard_charges":[{"gross_charge":3351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOMETRIAL BIOPSY W WO ENDOCERV BIOPSY WO DILAT SEP PROC","code_information":[{"code":"5100000732","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58100","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOMETRIAL BIOPSY IN CONJUNCTION W COLPOSCOPY","code_information":[{"code":"5100000733","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58110","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT INTRAUTERINE DEVICE IUD","code_information":[{"code":"5100000735","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58300","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM INTRAUTERINE DEVICE IUD","code_information":[{"code":"5100000736","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58301","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CATH AND INTRO OF SAL OR CONTR SONOHYSTER HYSTEROSALP","code_information":[{"code":"5100000737","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58340","type":"HCPCS"}],"standard_charges":[{"gross_charge":395.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FETAL CONTRACTION STRESS TEST","code_information":[{"code":"5100000741","type":"CDM"},{"code":"0920","type":"RC"},{"code":"59020","type":"HCPCS"}],"standard_charges":[{"gross_charge":549.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FETAL NON STRESS TEST","code_information":[{"code":"5100000742","type":"CDM"},{"code":"0920","type":"RC"},{"code":"59025","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY THYROID PERC CORE NEEDLE","code_information":[{"code":"5100000743","type":"CDM"},{"code":"0510","type":"RC"},{"code":"60100","type":"HCPCS"}],"standard_charges":[{"gross_charge":2076.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASPIRATION AND OR INJ THYROID CYST","code_information":[{"code":"5100000744","type":"CDM"},{"code":"0510","type":"RC"},{"code":"60300","type":"HCPCS"}],"standard_charges":[{"gross_charge":1298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CISTERNAL OR LATERAL C1 C2 PUNCTURE W INJ","code_information":[{"code":"5100000746","type":"CDM"},{"code":"0510","type":"RC"},{"code":"61055","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH PERMAN OCCLUSION OR EMBOLIZATION PERC CNS","code_information":[{"code":"5100000748","type":"CDM"},{"code":"0510","type":"RC"},{"code":"61624","type":"HCPCS"}],"standard_charges":[{"gross_charge":2208.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH PERMAN OCCLUSION OR EMBOLIZATION PERC NON CNS","code_information":[{"code":"5100000749","type":"CDM"},{"code":"0510","type":"RC"},{"code":"61626","type":"HCPCS"}],"standard_charges":[{"gross_charge":20504.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC ASPIR PULPOSUS INTERVERTEBRAL DISC PARAVERT TISS","code_information":[{"code":"5100000754","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62267","type":"HCPCS"}],"standard_charges":[{"gross_charge":1193.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPINAL PUNCTURE LUMBAR DIAGNOSTIC","code_information":[{"code":"5100000755","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62270","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ EPIDURAL OF BLOOD OR CLOT PATCH","code_information":[{"code":"5100000756","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62273","type":"HCPCS"}],"standard_charges":[{"gross_charge":2334.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC MYELOGRAPHY OR TOMOGRAPHY CT LUMBAR","code_information":[{"code":"5100000757","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62284","type":"HCPCS"}],"standard_charges":[{"gross_charge":2457.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC DISCOGRAPHY EA LEVEL LUMBAR","code_information":[{"code":"5100000758","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62290","type":"HCPCS"}],"standard_charges":[{"gross_charge":6869.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMPLANT REV OR REPL INTRACATH OR EPID CATH PMP WO LAM","code_information":[{"code":"5100000763","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62350","type":"HCPCS"}],"standard_charges":[{"gross_charge":10218.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMPLANT REV OR REPL INTRACATH OR EPID DRUG NFS SUBC RES","code_information":[{"code":"5100000764","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62360","type":"HCPCS"}],"standard_charges":[{"gross_charge":6368.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECT ANALYSIS IMPLANT INTRACATH OR EPID PUMP WO REPR REFILL","code_information":[{"code":"5100000765","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62367","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECT ANALYSIS IMPLANT INTRACATH OR EPID PUMP W REPRGRM","code_information":[{"code":"5100000766","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62368","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC IMPLT NEUROSTIM ELECTRODE ARRAY EPIDURAL","code_information":[{"code":"5100000767","type":"CDM"},{"code":"0510","type":"RC"},{"code":"63650","type":"HCPCS"}],"standard_charges":[{"gross_charge":13223.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES TRIGEMINAL NERVE ANY DIVISON OR BRANCH","code_information":[{"code":"5100000768","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64400","type":"HCPCS"}],"standard_charges":[{"gross_charge":642.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT GREATER OCCIPITAL NERVE","code_information":[{"code":"5100000770","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1002.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT BRACHIAL PLEXUS SINGLE W/IMG GDN","code_information":[{"code":"5100000772","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64415","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT BRACHIAL PLEXUS CONT INFUSION CATH W/IMG GDN","code_information":[{"code":"5100000773","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64416","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT SUPRASCAPULAR NERVE","code_information":[{"code":"5100000774","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64418","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT INTERCOSTAL NERVE SINGLE","code_information":[{"code":"5100000775","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64420","type":"HCPCS"}],"standard_charges":[{"gross_charge":1130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT INTERCOSTAL NERVE MULTI REGL BLOCK","code_information":[{"code":"5100000776","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64421","type":"HCPCS"}],"standard_charges":[{"gross_charge":1588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT ILIOINGUINAL ILIOHYPOGASTRIC NERVES","code_information":[{"code":"5100000777","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64425","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT SCIATIC NERVE SINGLE W/IMG GDN","code_information":[{"code":"5100000778","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64445","type":"HCPCS"}],"standard_charges":[{"gross_charge":2156.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT FEMORAL NERVE SINGLE W/IMG GDN","code_information":[{"code":"5100000779","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64447","type":"HCPCS"}],"standard_charges":[{"gross_charge":638.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT FEMORAL NERVE CONT INFUSION CATH W/IMG GDN","code_information":[{"code":"5100000780","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64448","type":"HCPCS"}],"standard_charges":[{"gross_charge":3351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENT LUMBAR PLEXUS POSTR CONT INFUSION CATH","code_information":[{"code":"5100000781","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64449","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AGENTOTHER PERIPHERAL NERVE OR BRANCH","code_information":[{"code":"5100000782","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AND OR STEROID PLANTAR COM DIGITAL NERVE","code_information":[{"code":"5100000783","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64455","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AND OR STRD W IMG TFRML EDRL CRV THRC SING LEVEL","code_information":[{"code":"5100000784","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64479","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AND OR STRD W IMG TFRML EDRL CRV THRC EA LEVEL","code_information":[{"code":"5100000785","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64480","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AND OR STRD W IMG TFRML EDRL LMBR SAC SING LEVEL","code_information":[{"code":"5100000786","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64483","type":"HCPCS"}],"standard_charges":[{"gross_charge":1167.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES AND OR STRD W IMG TFRML EDRL LMBR SAC EA LEVEL","code_information":[{"code":"5100000787","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64484","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DIAG OR THER AGNT PVRT FACET JOINT CRV SINGLE LEVEL","code_information":[{"code":"5100000788","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64490","type":"HCPCS"}],"standard_charges":[{"gross_charge":2757.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DIAG OR THER AGNT PVRT FACET JOINT CRV 2ND LEVEL","code_information":[{"code":"5100000789","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64491","type":"HCPCS"}],"standard_charges":[{"gross_charge":1381.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DIAG OR THER AGNT PVRT FACET JOINT CRV 3RD PLUS","code_information":[{"code":"5100000790","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64492","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DIAG OR THER AGNT PVRT FACET JOINT LMBR SAC SING LEVEL","code_information":[{"code":"5100000791","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64493","type":"HCPCS"}],"standard_charges":[{"gross_charge":1699.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DIAG OR THER AGNT PVRT FACET JOINT LMBR SAC 2ND LEVEL","code_information":[{"code":"5100000792","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64494","type":"HCPCS"}],"standard_charges":[{"gross_charge":1381.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ DAIG OR THER AGNT PVRT FACET JOINT LMBR SACRL 3RD PLUS","code_information":[{"code":"5100000793","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64495","type":"HCPCS"}],"standard_charges":[{"gross_charge":1340.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES STELLATE GANGLION CERVICAL SYMPATHETIC","code_information":[{"code":"5100000794","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64510","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES SUPERIOR HYPOGASTRIC PLEXUS","code_information":[{"code":"5100000795","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64517","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES LUMBAR OR THORACIC PARAVERTBRL SYMPATHETIC","code_information":[{"code":"5100000796","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64520","type":"HCPCS"}],"standard_charges":[{"gross_charge":1151.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ ANES CELIAC PLEXUS W WO RADIOLOGIC MONITORING","code_information":[{"code":"5100000797","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64530","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRQ IMPLT NEUROSTIM ELTRD SACRAL NRVE W IMG","code_information":[{"code":"5100000798","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64561","type":"HCPCS"}],"standard_charges":[{"gross_charge":20378.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV MUSCLE INNERVATED FACIAL NERVE UNI","code_information":[{"code":"5100000801","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64612","type":"HCPCS"}],"standard_charges":[{"gross_charge":1611.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV FACIAL TRIGEM CERV SPINAL AND NERVES BI","code_information":[{"code":"5100000802","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64615","type":"HCPCS"}],"standard_charges":[{"gross_charge":1611.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV MUSCLE NECK UNI","code_information":[{"code":"5100000803","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64616","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTR NEUROLYTIC AGENT INTERCOSTAL NRV","code_information":[{"code":"5100000804","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64620","type":"HCPCS"}],"standard_charges":[{"gross_charge":3351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR NROLYTC AGNT PARVERTEB FCT SINGLE CRVCL OR THORA","code_information":[{"code":"5100000805","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64633","type":"HCPCS"}],"standard_charges":[{"gross_charge":3968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR NROLYTC AGNT PARVERTEB FCT EA ADDL CRVCL OR THORA","code_information":[{"code":"5100000806","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64634","type":"HCPCS"}],"standard_charges":[{"gross_charge":1924.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR NROLYTC AGNT PARVERTEB FCT SINGLE LMBR OR SACRAL","code_information":[{"code":"5100000807","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64635","type":"HCPCS"}],"standard_charges":[{"gross_charge":3412.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR NROLYTC AGNT PARVERTEB FCT EA ADDL LMBR OR SACRAL","code_information":[{"code":"5100000808","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64636","type":"HCPCS"}],"standard_charges":[{"gross_charge":1924.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTR NEUROLYTIC AGENT OTHER PERIPHERAL NERVE OR BRANCH","code_information":[{"code":"5100000809","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64640","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV OF TRUNK MUSCLE 1 TO 5 MUSCLES","code_information":[{"code":"5100000810","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64646","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV OF TRUNK 6 OR MORE MUSCLES","code_information":[{"code":"5100000811","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64647","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTR NEUROLYTIC W WO RAD MONITOR CELIAC PLEXUS","code_information":[{"code":"5100000813","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64680","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEUROPLASTY AND OR TRANSPOS MEDIAN NERVE CARPAL TUNNEL","code_information":[{"code":"5100000814","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64721","type":"HCPCS"}],"standard_charges":[{"gross_charge":5188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIER BLOCK","code_information":[{"code":"5100000817","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":7797.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GANGLION IMPAR BLOCK","code_information":[{"code":"5100000820","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":531.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PULS RADIO FREQ ABLA ABD WA","code_information":[{"code":"5100000822","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1323.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC QUTENZA PATCH","code_information":[{"code":"5100000824","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SYNOVIAL CYST ASPIRATION OF FA","code_information":[{"code":"5100000826","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":2070.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF FOREIGN BODY EYE CONJUNCTIVAL SUPERFICIAL","code_information":[{"code":"5100000827","type":"CDM"},{"code":"0510","type":"RC"},{"code":"65205","type":"HCPCS"}],"standard_charges":[{"gross_charge":570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF FOREIGN BODY EXTERN EYE EMBED SUBCON OR SCLERAL","code_information":[{"code":"5100000828","type":"CDM"},{"code":"0510","type":"RC"},{"code":"65210","type":"HCPCS"}],"standard_charges":[{"gross_charge":714.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF FOREIGN BODY EXTERN EYE CORNEAL WO SLIT LAMP","code_information":[{"code":"5100000829","type":"CDM"},{"code":"0510","type":"RC"},{"code":"65220","type":"HCPCS"}],"standard_charges":[{"gross_charge":705.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF FOREIGN BODY EXTERN EYE CORNEAL W SLIT LAMP","code_information":[{"code":"5100000830","type":"CDM"},{"code":"0510","type":"RC"},{"code":"65222","type":"HCPCS"}],"standard_charges":[{"gross_charge":578.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IRIDOTOMY OR IRRIDECTOMY LASER SURG PER SESSION","code_information":[{"code":"5100000844","type":"CDM"},{"code":"0510","type":"RC"},{"code":"66761","type":"HCPCS"}],"standard_charges":[{"gross_charge":2250.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DISC SECONDARY MEMBRANE CATARACT LASER SURGERY","code_information":[{"code":"5100000845","type":"CDM"},{"code":"0510","type":"RC"},{"code":"66821","type":"HCPCS"}],"standard_charges":[{"gross_charge":2217.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM LENS MATERIAL EXTRACAPSULAR","code_information":[{"code":"5100000846","type":"CDM"},{"code":"0510","type":"RC"},{"code":"66940","type":"HCPCS"}],"standard_charges":[{"gross_charge":9840.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRAVITREAL INJ PHARMACOLOGIC AGNT SEP RROC","code_information":[{"code":"5100000848","type":"CDM"},{"code":"0510","type":"RC"},{"code":"67028","type":"HCPCS"}],"standard_charges":[{"gross_charge":1270.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV EXTRAOCULAR MUSCLE","code_information":[{"code":"5100000858","type":"CDM"},{"code":"0510","type":"RC"},{"code":"67345","type":"HCPCS"}],"standard_charges":[{"gross_charge":8930.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BLEPHAROTOMY DRAIN OF ABSCESS EYELID","code_information":[{"code":"5100000860","type":"CDM"},{"code":"0510","type":"RC"},{"code":"67700","type":"HCPCS"}],"standard_charges":[{"gross_charge":976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN EXTERNAL EAR ABSCESS HEMATOMA SIMPLE","code_information":[{"code":"5100000883","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69000","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN EXTERNAL AUDITORY CANAL ABSCESS","code_information":[{"code":"5100000885","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69020","type":"HCPCS"}],"standard_charges":[{"gross_charge":794.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OF FOREIGN BODY EXTERN AUDITORY CANAL WO GEN ANES","code_information":[{"code":"5100000891","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69200","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM IMPACTED CERUMEN INSTRUMENTATION UNI","code_information":[{"code":"5100000892","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69210","type":"HCPCS"}],"standard_charges":[{"gross_charge":321.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC END AGILE PATENCY CAPSUL ADMIN","code_information":[{"code":"5100000903","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91299","type":"HCPCS"}],"standard_charges":[{"gross_charge":3423.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDE OPEN WOUND 1ST 20 CM OR LESS","code_information":[{"code":"5100000908","type":"CDM"},{"code":"0510","type":"RC"},{"code":"97597","type":"HCPCS"}],"standard_charges":[{"gross_charge":346.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEBRIDEMENT OPEN WOUND EA ADD 20 SQ CM","code_information":[{"code":"5100000909","type":"CDM"},{"code":"0510","type":"RC"},{"code":"97598","type":"HCPCS"}],"standard_charges":[{"gross_charge":336.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM DEVITAL TISS NON SELECTIVE DEBRIDE WO ANES 1 SESS","code_information":[{"code":"5100000910","type":"CDM"},{"code":"0510","type":"RC"},{"code":"97602","type":"HCPCS"}],"standard_charges":[{"gross_charge":230.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEG PRESS WOUND THER 50 SQ CM OR LESS","code_information":[{"code":"5100000911","type":"CDM"},{"code":"0510","type":"RC"},{"code":"97605","type":"HCPCS"}],"standard_charges":[{"gross_charge":329.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEG PRESS WOUND THER GREATER THAN 50 SQ CM","code_information":[{"code":"5100000912","type":"CDM"},{"code":"0510","type":"RC"},{"code":"97606","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED FACE EARS NOSE ETC 5.1 TO 7.5 CM","code_information":[{"code":"5100000913","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12053","type":"HCPCS"}],"standard_charges":[{"gross_charge":934.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP INTERMED FACE EARS NOSE ETC 7.6 TO 12.5 CM","code_information":[{"code":"5100000914","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12054","type":"HCPCS"}],"standard_charges":[{"gross_charge":434.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT ULNAR FRACTURE PROXIMAL END WO MANIP","code_information":[{"code":"5100000916","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24670","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX SCALP ARMS AND OR LEGS EA ADDL 5 CM OR LESS","code_information":[{"code":"5100000917","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13122","type":"HCPCS"}],"standard_charges":[{"gross_charge":243.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP COMPLEX TRUNK 2.6 TO 7.5 CM","code_information":[{"code":"5100000918","type":"CDM"},{"code":"0510","type":"RC"},{"code":"13101","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC SACROILIAC JOINT W IMAGE GUIDANCE","code_information":[{"code":"5100000919","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27096","type":"HCPCS"}],"standard_charges":[{"gross_charge":1714.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INITIAL PREVENTIVE MED NEW PT AGE 65 YRS OR MORE","code_information":[{"code":"5100000931","type":"CDM"},{"code":"0770","type":"RC"},{"code":"99387","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERIODIC PREVENTIVE MED EST PT AGE 18 TO 39 YRS","code_information":[{"code":"5100000933","type":"CDM"},{"code":"0770","type":"RC"},{"code":"99395","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERIODIC PREVENTIVE MED EST PT AGE 40 TO 64 YRS","code_information":[{"code":"5100000934","type":"CDM"},{"code":"0770","type":"RC"},{"code":"99396","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERIODIC PREVENTIVE MED EST PT AGE 65 YRS OR MORE","code_information":[{"code":"5100000935","type":"CDM"},{"code":"0770","type":"RC"},{"code":"99397","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PREV MED COUNSEL AND OR RISK FACTOR RED INTERV IND 30 MIN","code_information":[{"code":"5100000937","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99402","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSITIONAL CARE MGMNT SER WITHIN 14 CAL DAYS OF DISCH","code_information":[{"code":"5100000942","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99495","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT NEW PT LEVEL 2","code_information":[{"code":"5100000949","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99202","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT NEW PT LEVEL 3","code_information":[{"code":"5100000950","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99203","type":"HCPCS"}],"standard_charges":[{"gross_charge":258.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT NEW PT LEVEL 4","code_information":[{"code":"5100000951","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99204","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT NEW PT LEVEL 5","code_information":[{"code":"5100000952","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99205","type":"HCPCS"}],"standard_charges":[{"gross_charge":722.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT EST PT LEVEL 1","code_information":[{"code":"5100000953","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT EST PT LEVEL 2","code_information":[{"code":"5100000954","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99212","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT EST PT LEVEL 3","code_information":[{"code":"5100000955","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99213","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT EST PT LEVEL 4","code_information":[{"code":"5100000956","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99214","type":"HCPCS"}],"standard_charges":[{"gross_charge":258.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OFFICE OR OP VISIT EST PT LEVEL 5","code_information":[{"code":"5100000957","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99215","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPINAL PUNCTURE THERA DRGE CEREBROSPINAL FLUID","code_information":[{"code":"5100000958","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62272","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC PILONIDAL CYST OR SINUS COMPLICATED","code_information":[{"code":"5100000959","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11772","type":"HCPCS"}],"standard_charges":[{"gross_charge":8887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST W DEVICE 1ST LESION STEREOTACTIC GUIDE","code_information":[{"code":"5100000960","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19081","type":"HCPCS"}],"standard_charges":[{"gross_charge":2551.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST W DEVICE EA ADDL LESION STEREOTACTIC GUIDE","code_information":[{"code":"5100000961","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19082","type":"HCPCS"}],"standard_charges":[{"gross_charge":531.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST W DEVICE 1ST LESION ULTRASOUND GUIDE","code_information":[{"code":"5100000962","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19083","type":"HCPCS"}],"standard_charges":[{"gross_charge":2181.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST W DEVICE EA ADDL LESION ULTRASOUND GUIDE","code_information":[{"code":"5100000963","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19084","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY BREAST W DEVICE 1ST LESION MAGNETIC RES GUIDE","code_information":[{"code":"5100000964","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19085","type":"HCPCS"}],"standard_charges":[{"gross_charge":2420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ DEV PLACMNT BREAST LOC 1ST LESION W MAMMO GUIDE","code_information":[{"code":"5100000965","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19281","type":"HCPCS"}],"standard_charges":[{"gross_charge":1853.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ DEV PLACMNT BREAST LOC EA ADDL LESION  W GUIDE","code_information":[{"code":"5100000966","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19282","type":"HCPCS"}],"standard_charges":[{"gross_charge":546.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ DEV PLACMNT 1ST LESION ULTRASOUND GUIDE","code_information":[{"code":"5100000967","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19285","type":"HCPCS"}],"standard_charges":[{"gross_charge":899.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS BACK FLANK SUBF LESS THAN 5 CM","code_information":[{"code":"5100000972","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21932","type":"HCPCS"}],"standard_charges":[{"gross_charge":4577.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS UPPER ARM ELBOW SUBQ LESS THAN 3 CM","code_information":[{"code":"5100000977","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24075","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT SUP OR TRAN HUM FRACTURE W WO SKIN OR SKEL TRAC","code_information":[{"code":"5100000979","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24535","type":"HCPCS"}],"standard_charges":[{"gross_charge":1551.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS THIGH KNEE SUBQ  LESS THAN 3 CM","code_information":[{"code":"5100000987","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27327","type":"HCPCS"}],"standard_charges":[{"gross_charge":3732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MANIP KNEE JOINT UNDER ANESTHESIA","code_information":[{"code":"5100000989","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27570","type":"HCPCS"}],"standard_charges":[{"gross_charge":2505.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TREAT METATARSAL PHLNGL JOINT DISL WO ANES","code_information":[{"code":"5100000993","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28630","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AMPUT TOE INTERPHALANGEAL JOINT","code_information":[{"code":"5100000994","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28825","type":"HCPCS"}],"standard_charges":[{"gross_charge":3790.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM OR BIVALVING FULL ARM OR FULL LEG CAST","code_information":[{"code":"5100000996","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29705","type":"HCPCS"}],"standard_charges":[{"gross_charge":847.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UNLISTED CASTING OR STRAPPING","code_information":[{"code":"5100000998","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29799","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN ABSCESS HEMATOMA NASAL INTER APPROACH","code_information":[{"code":"5100000999","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30000","type":"HCPCS"}],"standard_charges":[{"gross_charge":985.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLLECT BLOOD FROM CENTRAL OR PERIPH CATHETER VENOUS","code_information":[{"code":"5100001006","type":"CDM"},{"code":"0510","type":"RC"},{"code":"36592","type":"HCPCS"}],"standard_charges":[{"gross_charge":256.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA","code_information":[{"code":"5100001008","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37607","type":"HCPCS"}],"standard_charges":[{"gross_charge":9774.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OR EXC OF LYMPH NODE OPEN DEEP CERVICAL NODE","code_information":[{"code":"5100001010","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38510","type":"HCPCS"}],"standard_charges":[{"gross_charge":3912.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REP LAC OF TONG FLR OF MOUTH OVER 2.6 CM OR COMP","code_information":[{"code":"5100001015","type":"CDM"},{"code":"0510","type":"RC"},{"code":"41252","type":"HCPCS"}],"standard_charges":[{"gross_charge":4488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN OF ABSCESS ON PALATE OR UVULA","code_information":[{"code":"5100001017","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT DUODENOSTOMY OR J TUBE FLUOR GUIDE AND CONTR","code_information":[{"code":"5100001023","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49441","type":"HCPCS"}],"standard_charges":[{"gross_charge":7740.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO URETERO AND OR PYLSCPY W LITHO AND INDW STENT INSER","code_information":[{"code":"5100001027","type":"CDM"},{"code":"0510","type":"RC"},{"code":"52356","type":"HCPCS"}],"standard_charges":[{"gross_charge":15785.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CIRCUMCISION NOT BY CLAMP OR SLIT MORE THAN 28 DAYS","code_information":[{"code":"5100001031","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54161","type":"HCPCS"}],"standard_charges":[{"gross_charge":5585.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC VAGINAL CYST OR TUMOR","code_information":[{"code":"5100001035","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57135","type":"HCPCS"}],"standard_charges":[{"gross_charge":9873.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV ONE EXTREMITY 1 TO 4 MUSCLES","code_information":[{"code":"5100001038","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64642","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEM DENERV ONE EXTREMITY EA ADDL  EXT 1 TO 4 MUSCLES","code_information":[{"code":"5100001039","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64643","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC SACRAL AUGMENT BI INJ S INCL BALL OR DEV 2 OR MORE NDLS","code_information":[{"code":"5100001055","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0201T","type":"HCPCS"}],"standard_charges":[{"gross_charge":4469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC SWEAT GLAND LESN INGUIN,SIMPL","code_information":[{"code":"5100001063","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11462","type":"HCPCS"}],"standard_charges":[{"gross_charge":8887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FILL CONTOUR DEFCT >10CC","code_information":[{"code":"5100001067","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11954","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LAYR CLOS WND REST BODY 7.6-12.5 CM","code_information":[{"code":"5100001072","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12044","type":"HCPCS"}],"standard_charges":[{"gross_charge":951.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LAYR CLOS WND REST BODY 20.1-30 CM","code_information":[{"code":"5100001073","type":"CDM"},{"code":"0510","type":"RC"},{"code":"12046","type":"HCPCS"}],"standard_charges":[{"gross_charge":1900.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPLIT GRFT,TRUNK,ARM,LEG EA 100 SQCM","code_information":[{"code":"5100001078","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15101","type":"HCPCS"}],"standard_charges":[{"gross_charge":993.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APP SKN SUB GRFT T/A/L AREA/>100SCM ADL 100SCM","code_information":[{"code":"5100001084","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15274","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUSCLE-SKIN FLAP,TRUNK","code_information":[{"code":"5100001088","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15734","type":"HCPCS"}],"standard_charges":[{"gross_charge":6613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUSCLE-SKIN FLAP,LEG","code_information":[{"code":"5100001089","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15738","type":"HCPCS"}],"standard_charges":[{"gross_charge":6811.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT","code_information":[{"code":"5100001096","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15777","type":"HCPCS"}],"standard_charges":[{"gross_charge":616.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SKIN TISSUE PROCEDURE UNLISTED","code_information":[{"code":"5100001107","type":"CDM"},{"code":"0510","type":"RC"},{"code":"17999","type":"HCPCS"}],"standard_charges":[{"gross_charge":617.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BX BREAST W DEVICE ADDL LESION MAGNET RES GUIDE","code_information":[{"code":"5100001108","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19086","type":"HCPCS"}],"standard_charges":[{"gross_charge":242.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC GUID","code_information":[{"code":"5100001109","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19283","type":"HCPCS"}],"standard_charges":[{"gross_charge":1561.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC","code_information":[{"code":"5100001110","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19284","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE","code_information":[{"code":"5100001111","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19286","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MASTECTOMY, PARTIAL","code_information":[{"code":"5100001113","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19301","type":"HCPCS"}],"standard_charges":[{"gross_charge":11890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE BIOPSY,EXCISIONAL SUPERF","code_information":[{"code":"5100001117","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20240","type":"HCPCS"}],"standard_charges":[{"gross_charge":10197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BONE BIOPSY,EXCISIONAL DEEP","code_information":[{"code":"5100001118","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20245","type":"HCPCS"}],"standard_charges":[{"gross_charge":7424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASPIR/INJEC BONE CYST","code_information":[{"code":"5100001120","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20615","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABLATION BONE TUMOR RF PERQ WITH IMG GDN WHEN DONE","code_information":[{"code":"5100001121","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20982","type":"HCPCS"}],"standard_charges":[{"gross_charge":7740.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUSCULOSKELETAL SURGERY UNLISTED","code_information":[{"code":"5100001122","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20999","type":"HCPCS"}],"standard_charges":[{"gross_charge":7424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM","code_information":[{"code":"5100001123","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21012","type":"HCPCS"}],"standard_charges":[{"gross_charge":1895.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX DENTAL RIDGE FX","code_information":[{"code":"5100001131","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21440","type":"HCPCS"}],"standard_charges":[{"gross_charge":10070.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM","code_information":[{"code":"5100001134","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21552","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBFASCIAL  5+CM","code_information":[{"code":"5100001135","type":"CDM"},{"code":"0510","type":"RC"},{"code":"21554","type":"HCPCS"}],"standard_charges":[{"gross_charge":6210.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SPINE SURGERY PROCEDURE UNLISTED","code_information":[{"code":"5100001140","type":"CDM"},{"code":"0510","type":"RC"},{"code":"22899","type":"HCPCS"}],"standard_charges":[{"gross_charge":9126.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5+CM","code_information":[{"code":"5100001141","type":"CDM"},{"code":"0510","type":"RC"},{"code":"22901","type":"HCPCS"}],"standard_charges":[{"gross_charge":8887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3+CM","code_information":[{"code":"5100001142","type":"CDM"},{"code":"0510","type":"RC"},{"code":"22903","type":"HCPCS"}],"standard_charges":[{"gross_charge":5504.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABDOMEN WALL SURG PROC UNLISTED","code_information":[{"code":"5100001143","type":"CDM"},{"code":"0510","type":"RC"},{"code":"22999","type":"HCPCS"}],"standard_charges":[{"gross_charge":6811.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM","code_information":[{"code":"5100001145","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23076","type":"HCPCS"}],"standard_charges":[{"gross_charge":4962.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX STERNO-CLAV DISLOC","code_information":[{"code":"5100001147","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23520","type":"HCPCS"}],"standard_charges":[{"gross_charge":4761.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX SHLDR DISLOC,PROX HUM FX","code_information":[{"code":"5100001149","type":"CDM"},{"code":"0510","type":"RC"},{"code":"23675","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX HUMER EPICONDYLR FX,MANIP","code_information":[{"code":"5100001152","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24565","type":"HCPCS"}],"standard_charges":[{"gross_charge":3678.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY FOREARM SOFT TISSUES,SUPERFIC","code_information":[{"code":"5100001154","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25065","type":"HCPCS"}],"standard_charges":[{"gross_charge":6075.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERCUT RX IP JT DISLOCATION","code_information":[{"code":"5100001169","type":"CDM"},{"code":"0510","type":"RC"},{"code":"26776","type":"HCPCS"}],"standard_charges":[{"gross_charge":10075.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX INTER/SUBTROCH FEMUR FX","code_information":[{"code":"5100001174","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27238","type":"HCPCS"}],"standard_charges":[{"gross_charge":4801.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX SPONT HIP DISLOC,ANESTH","code_information":[{"code":"5100001176","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27257","type":"HCPCS"}],"standard_charges":[{"gross_charge":3820.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANIP","code_information":[{"code":"5100001177","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27267","type":"HCPCS"}],"standard_charges":[{"gross_charge":9734.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BX THIGH/KNEE SOFT TISSUES,SUPERF","code_information":[{"code":"5100001178","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27323","type":"HCPCS"}],"standard_charges":[{"gross_charge":5772.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX FEMUR,DISTAL+MANIP","code_information":[{"code":"5100001179","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27510","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX TIB PLAT FX+MANIP","code_information":[{"code":"5100001181","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27532","type":"HCPCS"}],"standard_charges":[{"gross_charge":10075.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX KNEE DISLOCATN","code_information":[{"code":"5100001183","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27550","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN LOWER LEG DEEP ABSC/HEMATOMA","code_information":[{"code":"5100001184","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27603","type":"HCPCS"}],"standard_charges":[{"gross_charge":8887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM","code_information":[{"code":"5100001187","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27618","type":"HCPCS"}],"standard_charges":[{"gross_charge":3753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECTION FOR ANKLE ARTHROGRAM","code_information":[{"code":"5100001189","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27648","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMV FOOT FOREIGN BODY,DEEP","code_information":[{"code":"5100001197","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28192","type":"HCPCS"}],"standard_charges":[{"gross_charge":5031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX TARSAL DISLOCATION","code_information":[{"code":"5100001201","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28540","type":"HCPCS"}],"standard_charges":[{"gross_charge":1270.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FOOT/TOES SURGERY PROC UNLISTED","code_information":[{"code":"5100001202","type":"CDM"},{"code":"0510","type":"RC"},{"code":"28899","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPLY FINGER SPLINT,DYNAMIC","code_information":[{"code":"5100001215","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29131","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC STRAPPING OF CHEST","code_information":[{"code":"5100001216","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29200","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KNEE SCOPE,MED/LAT MENISECTOMY","code_information":[{"code":"5100001229","type":"CDM"},{"code":"0510","type":"RC"},{"code":"29881","type":"HCPCS"}],"standard_charges":[{"gross_charge":10075.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXCIS NASAL DERMOID,SIMPLE,SUBCUT","code_information":[{"code":"5100001230","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30124","type":"HCPCS"}],"standard_charges":[{"gross_charge":4600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NASAL SURG PROC UNLISTED","code_information":[{"code":"5100001236","type":"CDM"},{"code":"0510","type":"RC"},{"code":"30999","type":"HCPCS"}],"standard_charges":[{"gross_charge":588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NASAL/SINUS ENDOSCOPY,REMV TOTL ETHMOID","code_information":[{"code":"5100001243","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31255","type":"HCPCS"}],"standard_charges":[{"gross_charge":21494.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NASAL/SINUS ENDOSCOPY,OPEN MAXILL SINUS","code_information":[{"code":"5100001244","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31256","type":"HCPCS"}],"standard_charges":[{"gross_charge":11448.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LARYNGOSCOPY,INDIRECT+REMV FOR.BODY","code_information":[{"code":"5100001252","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31511","type":"HCPCS"}],"standard_charges":[{"gross_charge":1139.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSTILL VIA CHEST TUBE AGENT FOR FIBRINOLYSIS, SUBSEQUENT","code_information":[{"code":"5100001269","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32562","type":"HCPCS"}],"standard_charges":[{"gross_charge":2198.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ RADIOFREQ ABLATION TX, PUL TUMOR","code_information":[{"code":"5100001271","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32998","type":"HCPCS"}],"standard_charges":[{"gross_charge":8999.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL FOREIGN BODY,MOUTH,SIMPLE","code_information":[{"code":"5100001281","type":"CDM"},{"code":"0510","type":"RC"},{"code":"40804","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC I&D MOUTH/TONG INTRA,SUBMANDIBULAR","code_information":[{"code":"5100001287","type":"CDM"},{"code":"0510","type":"RC"},{"code":"41008","type":"HCPCS"}],"standard_charges":[{"gross_charge":3066.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DENTAL SURGERY PROCEDURE","code_information":[{"code":"5100001298","type":"CDM"},{"code":"0510","type":"RC"},{"code":"41899","type":"HCPCS"}],"standard_charges":[{"gross_charge":643.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPAIR PALATE LACER <2 CM","code_information":[{"code":"5100001301","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42180","type":"HCPCS"}],"standard_charges":[{"gross_charge":1124.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN ABSCESS PAROTID,SIMPLE","code_information":[{"code":"5100001303","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42300","type":"HCPCS"}],"standard_charges":[{"gross_charge":5735.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DRAIN ABSC-SUBMAX-EXTERNAL","code_information":[{"code":"5100001304","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42320","type":"HCPCS"}],"standard_charges":[{"gross_charge":1193.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY SALIVARY GLAND,INCISIONAL","code_information":[{"code":"5100001306","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42405","type":"HCPCS"}],"standard_charges":[{"gross_charge":5735.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE PHARYNX FOREIGN BODY","code_information":[{"code":"5100001313","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42809","type":"HCPCS"}],"standard_charges":[{"gross_charge":527.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONTROL THROAT BLEED,SIMPLE","code_information":[{"code":"5100001318","type":"CDM"},{"code":"0510","type":"RC"},{"code":"42960","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC I&D RECTAL WALL ABSCESS W ANESTH","code_information":[{"code":"5100001324","type":"CDM"},{"code":"0510","type":"RC"},{"code":"46045","type":"HCPCS"}],"standard_charges":[{"gross_charge":8515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIL URET STRIC,MALE,INIT,FILIFORM","code_information":[{"code":"5100001340","type":"CDM"},{"code":"0510","type":"RC"},{"code":"53620","type":"HCPCS"}],"standard_charges":[{"gross_charge":5621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PREPUTIAL STRETCHING","code_information":[{"code":"5100001349","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OF VAGINA,EXTENSIVE","code_information":[{"code":"5100001354","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57105","type":"HCPCS"}],"standard_charges":[{"gross_charge":9539.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPAIR VAGINA/PERINEUM","code_information":[{"code":"5100001355","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57210","type":"HCPCS"}],"standard_charges":[{"gross_charge":9873.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CAUTERIZATION,CERVIX,ELECTRO/THERMAL","code_information":[{"code":"5100001357","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57510","type":"HCPCS"}],"standard_charges":[{"gross_charge":2571.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRYOCAUTERY OF CERVIX","code_information":[{"code":"5100001358","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57511","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DILATION OF CERVICAL CANAL","code_information":[{"code":"5100001360","type":"CDM"},{"code":"0510","type":"RC"},{"code":"57800","type":"HCPCS"}],"standard_charges":[{"gross_charge":2698.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT NERV BLCK,AXILLARY NERV W/IMG GDN","code_information":[{"code":"5100001370","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64417","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT NERV BLCK,PUDENDAL","code_information":[{"code":"5100001371","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64430","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT NERV BLCK,SPHENOPALAT GANGLN","code_information":[{"code":"5100001372","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64505","type":"HCPCS"}],"standard_charges":[{"gross_charge":6587.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCISION,IMPLANT,NEUROELEC,SACRAL NERVE","code_information":[{"code":"5100001373","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64581","type":"HCPCS"}],"standard_charges":[{"gross_charge":20378.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES","code_information":[{"code":"5100001375","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64644","type":"HCPCS"}],"standard_charges":[{"gross_charge":1118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMODENERV ECCRINE GLANDS, NON-AXILLARY","code_information":[{"code":"5100001376","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64653","type":"HCPCS"}],"standard_charges":[{"gross_charge":1270.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LASER SURGERY,SEVER VITREOUS STRANDS","code_information":[{"code":"5100001392","type":"CDM"},{"code":"0510","type":"RC"},{"code":"67031","type":"HCPCS"}],"standard_charges":[{"gross_charge":2284.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUTURE EYELID WOUND,PARTIAL THICK","code_information":[{"code":"5100001411","type":"CDM"},{"code":"0510","type":"RC"},{"code":"67930","type":"HCPCS"}],"standard_charges":[{"gross_charge":6913.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE EYELID FOREIGN BODY,EMBEDDED","code_information":[{"code":"5100001412","type":"CDM"},{"code":"0510","type":"RC"},{"code":"67938","type":"HCPCS"}],"standard_charges":[{"gross_charge":897.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMV EXT CANAL F.B.,GEN ANESTH","code_information":[{"code":"5100001422","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69205","type":"HCPCS"}],"standard_charges":[{"gross_charge":3241.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROCNT ASPIR AND INJ SM JT BURSA W US REC RPRT","code_information":[{"code":"5100001443","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20604","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROCNT ASPIR AND INJ INTERM JT BURSA W US","code_information":[{"code":"5100001444","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20606","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTHROCNT ASPIR AND INJ MAJOR JT BURSA W US","code_information":[{"code":"5100001445","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20611","type":"HCPCS"}],"standard_charges":[{"gross_charge":536.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPROGRAM REFILL IMPL SPINAL PUMP BY MD","code_information":[{"code":"5100001449","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62370","type":"HCPCS"}],"standard_charges":[{"gross_charge":7797.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIGID OR FLEX INC FLURO W EBUS GUIDE DURING BRONCH DX OR TX W SAMPLE 1 OR 2 LYMPH NODES","code_information":[{"code":"5100001452","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31652","type":"HCPCS"}],"standard_charges":[{"gross_charge":13135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRONCH RIGID OR FLEX INC FLURO W EBUS DURING BRONCH DX OR TX W SMPL 3 OR > LYMPH NODES","code_information":[{"code":"5100001453","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31653","type":"HCPCS"}],"standard_charges":[{"gross_charge":13135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC FOR CHOLANGIO PERC COMPLETE DX PROC INC IMAGE GUIDE","code_information":[{"code":"5100001455","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47531","type":"HCPCS"}],"standard_charges":[{"gross_charge":4079.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC FOR CHOLANGIO PERC COMPLETE DX PROC INC IMAGE GUIDE NEW ACCESS","code_information":[{"code":"5100001456","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47532","type":"HCPCS"}],"standard_charges":[{"gross_charge":4196.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACE BILIARY DRAIN CATH PERC INC DX CHOLANGIO PRFRMD IMAGE GUIDE EXTERNAL","code_information":[{"code":"5100001457","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47533","type":"HCPCS"}],"standard_charges":[{"gross_charge":4022.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACE BILIARY DRAIN CATH PERC INC DX CHOLANGIO PRFRMD IMAGE GUIDE INTERNAL TO EXTERNAL","code_information":[{"code":"5100001458","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47534","type":"HCPCS"}],"standard_charges":[{"gross_charge":6145.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXCHANGE EXTRNL TO INTRNL BILIARY DRAIN CATH PERC INC DX CHOLANGIO PRFRMD IMAGE GUIDE","code_information":[{"code":"5100001459","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47536","type":"HCPCS"}],"standard_charges":[{"gross_charge":5291.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BILE DUCT STENT PERC INC DX CHOLANG IMAGE GUIDE BAL DILAT CATH EA STENT EXISTING ACCES","code_information":[{"code":"5100001460","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47538","type":"HCPCS"}],"standard_charges":[{"gross_charge":8377.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BALLOON DIL BIL DUCT/AMPULLA PERC INC IMAGE GUIDE & ASSOC RAD SI EA DUCT","code_information":[{"code":"5100001463","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47542","type":"HCPCS"}],"standard_charges":[{"gross_charge":8744.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM CALCULI/DEBRIS BILIARY DUCT(S) AND/OR GALLBLADR PERC INC CALC DEST PERF IMG GUIDE","code_information":[{"code":"5100001465","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47544","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM IMPACTED CERUMEN IRREGATION OR LEVAGE UNI","code_information":[{"code":"5100001466","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69209","type":"HCPCS"}],"standard_charges":[{"gross_charge":208.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOLUMINAL BX URETER AND/OR RENAL PELVIS NON TO ENDOSCOPIC INC IMAGE GUIDE","code_information":[{"code":"5100001467","type":"CDM"},{"code":"0510","type":"RC"},{"code":"50606","type":"HCPCS"}],"standard_charges":[{"gross_charge":7797.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BALLOON DILATION URETERAL STRICTURE INC IMAGE GUIDE","code_information":[{"code":"5100001469","type":"CDM"},{"code":"0510","type":"RC"},{"code":"50706","type":"HCPCS"}],"standard_charges":[{"gross_charge":624.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SCLEROTHERAPY OF FLUID COLLECTION PERC INC CONTRAST INJ(S) SCLEROSANT INJ(S) DX STUDY IMAGE GUIDE","code_information":[{"code":"5100001471","type":"CDM"},{"code":"0510","type":"RC"},{"code":"49185","type":"HCPCS"}],"standard_charges":[{"gross_charge":1786.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE BILIARY DRAIN CATH PERC REQ FLUOROSCOP GUIDE INC DX CHOLANGIO PRFRMD IMAGE GUIDE","code_information":[{"code":"5100001472","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47537","type":"HCPCS"}],"standard_charges":[{"gross_charge":1398.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEPRESSION SCREEN ANNUAL","code_information":[{"code":"5100001474","type":"CDM"},{"code":"0510","type":"RC"},{"code":"G0444","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADVANCE CARE FIRST 30 MINUTES FACE TO FACE WITH PATIENT","code_information":[{"code":"5100001476","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99497","type":"HCPCS"}],"standard_charges":[{"gross_charge":199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADVANCE CARE EACH ADDL 30 MINUTES FACE TO FACE WITH PATIENT","code_information":[{"code":"5100001477","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99498","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISSUE ABD WALL SUBQ<3CM","code_information":[{"code":"5100001482","type":"CDM"},{"code":"0510","type":"RC"},{"code":"22902","type":"HCPCS"}],"standard_charges":[{"gross_charge":3732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR CRV THRC W O IMG GDN","code_information":[{"code":"5100001490","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62320","type":"HCPCS"}],"standard_charges":[{"gross_charge":1467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR CRV THRC W IMG GDN","code_information":[{"code":"5100001491","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62321","type":"HCPCS"}],"standard_charges":[{"gross_charge":1467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR LMBR SAC W O IMG GDN","code_information":[{"code":"5100001492","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62322","type":"HCPCS"}],"standard_charges":[{"gross_charge":1467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR LMBR SAC W IMG GDN","code_information":[{"code":"5100001493","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62323","type":"HCPCS"}],"standard_charges":[{"gross_charge":1467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR CRV THRC W O IMG GDN","code_information":[{"code":"5100001494","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62324","type":"HCPCS"}],"standard_charges":[{"gross_charge":1793.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR CRV THRC W IMG GDN","code_information":[{"code":"5100001495","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62325","type":"HCPCS"}],"standard_charges":[{"gross_charge":1793.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR LMBR SAC W O IMG GDN","code_information":[{"code":"5100001496","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62326","type":"HCPCS"}],"standard_charges":[{"gross_charge":1793.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  INJ DX THER SBST INTRLMNR LMBR SAC W IMG GDN","code_information":[{"code":"5100001497","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62327","type":"HCPCS"}],"standard_charges":[{"gross_charge":1793.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCISE AND DRAIN BLADDER","code_information":[{"code":"5100001499","type":"CDM"},{"code":"0510","type":"RC"},{"code":"51040","type":"HCPCS"}],"standard_charges":[{"gross_charge":6855.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ON Q PAIN PUMP INSERTION/CATHETER","code_information":[{"code":"5100001505","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FASCIA ILIACA BLOCK CONTINUOUS CATHETER","code_information":[{"code":"5100001507","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":2056.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBF ASC 5+CM","code_information":[{"code":"5100001511","type":"CDM"},{"code":"0510","type":"RC"},{"code":"24073","type":"HCPCS"}],"standard_charges":[{"gross_charge":6107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANTICOAGULANT MGMT FOR PT TAKING WARFARIN","code_information":[{"code":"5100001517","type":"CDM"},{"code":"0510","type":"RC"},{"code":"93793","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONT GLUC MONITORING PATIENT PROVIDED EQUIPTMENT","code_information":[{"code":"5100001518","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95249","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS","code_information":[{"code":"5100001523","type":"CDM"},{"code":"0510","type":"RC"},{"code":"38222","type":"HCPCS"}],"standard_charges":[{"gross_charge":2398.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC LAMINO LAMINECTOMY INDIR IMAG GUIDE LUMBAR","code_information":[{"code":"5100001539","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0275T","type":"HCPCS"}],"standard_charges":[{"gross_charge":22181.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTRUCT BY NEURO AGENT PUDENDAL","code_information":[{"code":"5100001540","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64630","type":"HCPCS"}],"standard_charges":[{"gross_charge":4743.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERECTOR SPINAE PLANE BLOCK,CONT INFUSION BY CATH(INCL IMAGE GUID","code_information":[{"code":"5100001542","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W O IMG GDN EA ADDL","code_information":[{"code":"5100001600","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10004","type":"HCPCS"}],"standard_charges":[{"gross_charge":127.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W US GDN 1ST LESION","code_information":[{"code":"5100001601","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10005","type":"HCPCS"}],"standard_charges":[{"gross_charge":1570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W US GDN EA ADDL","code_information":[{"code":"5100001602","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10006","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W FLUOR GDN 1ST LESION","code_information":[{"code":"5100001603","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10007","type":"HCPCS"}],"standard_charges":[{"gross_charge":1570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W CT GDN 1ST LESION","code_information":[{"code":"5100001605","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10009","type":"HCPCS"}],"standard_charges":[{"gross_charge":1570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W CT GDN EA ADDL","code_information":[{"code":"5100001606","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10010","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FINE NEEDLE ASPIRATION BX W MR GDN 1ST LESION","code_information":[{"code":"5100001607","type":"CDM"},{"code":"0510","type":"RC"},{"code":"10011","type":"HCPCS"}],"standard_charges":[{"gross_charge":1570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TANGENTIAL BIOPSY SKIN SINGLE LESION","code_information":[{"code":"5100001609","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11102","type":"HCPCS"}],"standard_charges":[{"gross_charge":480.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TANGENTIAL BIOPSY SKIN EA SEP ADDITIONAL LESION","code_information":[{"code":"5100001610","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11103","type":"HCPCS"}],"standard_charges":[{"gross_charge":438.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PUNCH BIOPSY SKIN SINGLE LESION","code_information":[{"code":"5100001611","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11104","type":"HCPCS"}],"standard_charges":[{"gross_charge":480.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PUNCH BIOPSY SKIN EA SEP ADDITIONAL LESION","code_information":[{"code":"5100001612","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11105","type":"HCPCS"}],"standard_charges":[{"gross_charge":438.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCISIONAL BIOPSY SKIN SINGLE LESION","code_information":[{"code":"5100001613","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11106","type":"HCPCS"}],"standard_charges":[{"gross_charge":853.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCISIONAL BIOPSY SKIN EA SEP ADDITIONAL LESION","code_information":[{"code":"5100001614","type":"CDM"},{"code":"0510","type":"RC"},{"code":"11107","type":"HCPCS"}],"standard_charges":[{"gross_charge":853.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC","code_information":[{"code":"5100001615","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43762","type":"HCPCS"}],"standard_charges":[{"gross_charge":629.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC","code_information":[{"code":"5100001616","type":"CDM"},{"code":"0510","type":"RC"},{"code":"43763","type":"HCPCS"}],"standard_charges":[{"gross_charge":629.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ DILATION XST TRC ENDOUROLOGIC PX W IMG","code_information":[{"code":"5100001617","type":"CDM"},{"code":"0510","type":"RC"},{"code":"50436","type":"HCPCS"}],"standard_charges":[{"gross_charge":5580.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ DILATION XST TRC NEW ACCESS RENAL COLTJ SYS","code_information":[{"code":"5100001618","type":"CDM"},{"code":"0510","type":"RC"},{"code":"50437","type":"HCPCS"}],"standard_charges":[{"gross_charge":9384.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OF TESTIS INCISIONAL","code_information":[{"code":"5100001621","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54505","type":"HCPCS"}],"standard_charges":[{"gross_charge":12288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PVB THORACIC CONT CATHETER INFUSION W/IMG GID","code_information":[{"code":"5100001624","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64463","type":"HCPCS"}],"standard_charges":[{"gross_charge":1632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL DEEP DRUG DELIVERY DEVICE","code_information":[{"code":"5100001628","type":"CDM"},{"code":"0510","type":"RC"},{"code":"20701","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W FLUOR OR CT","code_information":[{"code":"5100001633","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62328","type":"HCPCS"}],"standard_charges":[{"gross_charge":1627.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THERAPEUTIC SPINAL PNXR DRAINAGE CSF W FLUOR CT","code_information":[{"code":"5100001634","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62329","type":"HCPCS"}],"standard_charges":[{"gross_charge":1632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECTION AA& STRD NERVES NRVTG SI JOINT W IMG","code_information":[{"code":"5100001635","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64451","type":"HCPCS"}],"standard_charges":[{"gross_charge":1684.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECTION AA& STRD GENICULAR NRV BRANCHES W IMG","code_information":[{"code":"5100001636","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64454","type":"HCPCS"}],"standard_charges":[{"gross_charge":1952.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W IMG","code_information":[{"code":"5100001637","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64624","type":"HCPCS"}],"standard_charges":[{"gross_charge":4426.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXCISION OF LECT FOREARM VENOUS ANEURYSM","code_information":[{"code":"5100001645","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37799","type":"HCPCS"}],"standard_charges":[{"gross_charge":2207.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTERIAL DIGITAL PHOTOPLETHYSMOGRAPHY","code_information":[{"code":"5100001648","type":"CDM"},{"code":"0920","type":"RC"},{"code":"93998","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYS QHP TELE EVAL 5 TO 10 MIN","code_information":[{"code":"5100001649","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99441","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYS QHP TELE EVAL 11 TO 20 MIN","code_information":[{"code":"5100001650","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99442","type":"HCPCS"}],"standard_charges":[{"gross_charge":258.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYS QHP TELE EVAL 21 TO 30 MIN","code_information":[{"code":"5100001651","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99443","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT NONPHYSICIAN TELE ASSESSMENT 5 TO 10 MIN","code_information":[{"code":"5100001652","type":"CDM"},{"code":"0510","type":"RC"},{"code":"98966","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT NONPHYSICIAN TELE ASSESSMENT 11 TO 20 MIN","code_information":[{"code":"5100001653","type":"CDM"},{"code":"0510","type":"RC"},{"code":"98967","type":"HCPCS"}],"standard_charges":[{"gross_charge":258.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT NONPHYSICIAN TELE ASSESSMENT 21 TO 30 MIN","code_information":[{"code":"5100001654","type":"CDM"},{"code":"0510","type":"RC"},{"code":"98968","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CERVICAL PLEXUS NERVE BLOCK","code_information":[{"code":"5100001659","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY PENIS DEEP STRUCT","code_information":[{"code":"5100001662","type":"CDM"},{"code":"0510","type":"RC"},{"code":"54105","type":"HCPCS"}],"standard_charges":[{"gross_charge":8887.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IUD IINSERTION OR TREATMENT OF DISEASE","code_information":[{"code":"5100001663","type":"CDM"},{"code":"0510","type":"RC"},{"code":"58999","type":"HCPCS"}],"standard_charges":[{"gross_charge":624.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG","code_information":[{"code":"5100001668","type":"CDM"},{"code":"0510","type":"RC"},{"code":"32408","type":"HCPCS"}],"standard_charges":[{"gross_charge":2843.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PT PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN","code_information":[{"code":"5100001672","type":"CDM"},{"code":"0510","type":"RC"},{"code":"99417","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSED RX RADIAL SHAFT FX W/DISLOCATION","code_information":[{"code":"5100001686","type":"CDM"},{"code":"0510","type":"RC"},{"code":"25520","type":"HCPCS"}],"standard_charges":[{"gross_charge":4488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM","code_information":[{"code":"5100001693","type":"CDM"},{"code":"0510","type":"RC"},{"code":"97607","type":"HCPCS"}],"standard_charges":[{"gross_charge":1273.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LUMBORUM BLOCK UNILATERAL","code_information":[{"code":"5100001695","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERSTIM STAGE 2","code_information":[{"code":"5100001699","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64590","type":"HCPCS"}],"standard_charges":[{"gross_charge":66585.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLSD TX POSTERIOR PELVIC RING FX W O MANIPULATION","code_information":[{"code":"5100001708","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27197","type":"HCPCS"}],"standard_charges":[{"gross_charge":4743.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PENG BLOCK (PERICAPSULAR NERVE BLOCK GROUP) SINGLE INJECTION","code_information":[{"code":"5100001711","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1293.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERIPHERAL BLOCK; IPACK PECS FASCIA ILIACA SA SPANKS SINGLE INJ","code_information":[{"code":"5100001714","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1815.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PVB THORACIC SINGLE INJECTION SITE W/IMG GID","code_information":[{"code":"5100001715","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64461","type":"HCPCS"}],"standard_charges":[{"gross_charge":1586.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECTION AA&/STRD SCIATIC NERVE CONT NFS CATH W/IMG GDN","code_information":[{"code":"5100001716","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64446","type":"HCPCS"}],"standard_charges":[{"gross_charge":1634.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DISRUPTION OF FIBRIN SHEATH W ANGIOPLASTY BALLOON VIA SAME ACCESS","code_information":[{"code":"5100001717","type":"CDM"},{"code":"0510","type":"RC"},{"code":"37799","type":"HCPCS"}],"standard_charges":[{"gross_charge":1920.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANNUAL ALCOHOL SCREEN EA 15 MIN","code_information":[{"code":"5100001732","type":"CDM"},{"code":"0510","type":"RC"},{"code":"G0442","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPAIR OF ENTEROCUTANEOUS FISTULA SMALL INTESTINE OR COLON (EXCLUDING ANORECTAL FISTULA) WITH PLUG (E.G., PORCINE SMALL INTESTINE SUBMUCOSA","code_information":[{"code":"5100001750","type":"CDM"},{"code":"0510","type":"RC"},{"code":"C9796","type":"HCPCS"}],"standard_charges":[{"gross_charge":8227.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL SUTURES OR STAPLES NOT REQUIRING ANESTHESIA","code_information":[{"code":"5100001755","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15853","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL SUTURES AND STAPLES NOT REQUIRING ANESTHESIA","code_information":[{"code":"5100001756","type":"CDM"},{"code":"0510","type":"RC"},{"code":"15854","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERECTOR SPINAE PLANE BLOCKINJECTION/PARASTERNAL PLANE BLOCK INJECTION BILATERAL","code_information":[{"code":"5100001804","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":2612.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DETERMINATION REFRACTIVE STATE","code_information":[{"code":"5100001811","type":"CDM"},{"code":"0510","type":"RC"},{"code":"92015","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ","code_information":[{"code":"5100001815","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27502","type":"HCPCS"}],"standard_charges":[{"gross_charge":4969.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LARYNGOSCOPY FLEXIBLE THERAPEUTIC INJECTION UNI","code_information":[{"code":"5100001822","type":"CDM"},{"code":"0510","type":"RC"},{"code":"31573","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES","code_information":[{"code":"5100001826","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64645","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC  ESTEEM IMPLANT RMVL W/OSSICULAR CHAIN RECONSTRUCTN W/CARTILAGE GRT","code_information":[{"code":"5100001848","type":"CDM"},{"code":"0510","type":"RC"},{"code":"69799","type":"HCPCS"}],"standard_charges":[{"gross_charge":721.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CERCLAGE REMOVAL","code_information":[{"code":"5100001853","type":"CDM"},{"code":"0510","type":"RC"},{"code":"59899","type":"HCPCS"}],"standard_charges":[{"gross_charge":6003.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TCAT INSJ PERM DUAL CHAMBER LDLS PM COMPL SYS","code_information":[{"code":"5100001859","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0795T","type":"HCPCS"}],"standard_charges":[{"gross_charge":59215.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BRIEF ALCHL MISUSE CNSEL15MIN","code_information":[{"code":"5100001921","type":"CDM"},{"code":"0510","type":"RC"},{"code":"G0443","type":"HCPCS"}],"standard_charges":[{"gross_charge":330.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BEHAVIOR COUNSEL OBESITY 15M","code_information":[{"code":"5100001923","type":"CDM"},{"code":"0510","type":"RC"},{"code":"G0447","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OF AXILLA PERCUTANEOUS NEEDLE CORE WO IMG GUIDANCE","code_information":[{"code":"5100001926","type":"CDM"},{"code":"0510","type":"RC"},{"code":"19499","type":"HCPCS"}],"standard_charges":[{"gross_charge":11282.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BILE TRACT SURG PROC","code_information":[{"code":"5100001927","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47999","type":"HCPCS"}],"standard_charges":[{"gross_charge":7424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORACIC FASCIAL PLANE BLOCK UNIL INJECTION","code_information":[{"code":"5100001929","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64466","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORACIC FASCIAL PLANE BLOCK UNIL CONT INFUSION","code_information":[{"code":"5100001930","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64467","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORACIC FASCIAL PLANE BLOCK BIL INJECTION","code_information":[{"code":"5100001931","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64468","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THORACIC FASCIAL PLANE BLOCK BIL CONT INFUSION","code_information":[{"code":"5100001932","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64469","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LOWER XTR FASCIAL PLANE BLOCK UNIL INJECTION","code_information":[{"code":"5100001933","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64473","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LOWER XTR FASCIAL PLANE BLOCK UNIL CONT INFUSION","code_information":[{"code":"5100001934","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64474","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMP OPH DX IMG OCT ANGIOGRAPHY","code_information":[{"code":"5100001935","type":"CDM"},{"code":"0510","type":"RC"},{"code":"92137","type":"HCPCS"}],"standard_charges":[{"gross_charge":967.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMS THERAPY WND ASSMT&DR 1ST APPL <=50 SQ CM","code_information":[{"code":"5100001937","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0906T","type":"HCPCS"}],"standard_charges":[{"gross_charge":617.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMS THERAPY WND ASSMT&DR EA ADDL APPL<=50 SQ CM","code_information":[{"code":"5100001938","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0907T","type":"HCPCS"}],"standard_charges":[{"gross_charge":311.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HCR N-INVAS DETCN HEART FAILURE DRV AUGMNT ALYS ECHO W/I&R","code_information":[{"code":"5100001939","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0932T","type":"HCPCS"}],"standard_charges":[{"gross_charge":932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BX SOFT TISSUES,PELV/HIP,SUPERFICL","code_information":[{"code":"5100001950","type":"CDM"},{"code":"0510","type":"RC"},{"code":"27040","type":"HCPCS"}],"standard_charges":[{"gross_charge":5031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM","code_information":[{"code":"5100001951","type":"CDM"},{"code":"0510","type":"RC"},{"code":"96160","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NJX PLTLT PLASMA W/IMG HARVEST/PREPARATION","code_information":[{"code":"5100001960","type":"CDM"},{"code":"0510","type":"RC"},{"code":"0232T","type":"HCPCS"}],"standard_charges":[{"gross_charge":1239.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY","code_information":[{"code":"5100001961","type":"CDM"},{"code":"0510","type":"RC"},{"code":"62264","type":"HCPCS"}],"standard_charges":[{"gross_charge":2764.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PR ABLTN 1/+THYROID NODULE 1 LOBE/ISTHMUS PERQ RF","code_information":[{"code":"5100001962","type":"CDM"},{"code":"0510","type":"RC"},{"code":"60660","type":"HCPCS"}],"standard_charges":[{"gross_charge":5031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PR ABLTN 1/+THYROID NODULE ADDL LOBE PERQ RF","code_information":[{"code":"5100001963","type":"CDM"},{"code":"0510","type":"RC"},{"code":"60661","type":"HCPCS"}],"standard_charges":[{"gross_charge":500.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LAPS SURG ABLTJ 1/> LVR TUM RF","code_information":[{"code":"5100001964","type":"CDM"},{"code":"0510","type":"RC"},{"code":"47370","type":"HCPCS"}],"standard_charges":[{"gross_charge":32327.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTRJ NEURLYTIC TRIGEM NRV 2/3 DIV RADIO MONITOR","code_information":[{"code":"5100001965","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64610","type":"HCPCS"}],"standard_charges":[{"gross_charge":6063.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ORTHO K FITTING","code_information":[{"code":"5100001966","type":"CDM"},{"code":"0510","type":"RC"},{"code":"92499","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRIGEMINAL BALLOON W/O NEUROLYTIC","code_information":[{"code":"5100001970","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":917.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BIOPSY OF FAT PAD","code_information":[{"code":"5100001981","type":"CDM"},{"code":"0510","type":"RC"},{"code":"17999","type":"HCPCS"}],"standard_charges":[{"gross_charge":617.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DSTRJ NEUROLYTIC TRIGEMINAL NRV 2/3 DIV BRANCH","code_information":[{"code":"5100001987","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64605","type":"HCPCS"}],"standard_charges":[{"gross_charge":4341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HIS/LBB PACING","code_information":[{"code":"5100002903","type":"CDM"},{"code":"0510","type":"RC"},{"code":"33999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1920.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC LEADLESS PACEMAKER VR","code_information":[{"code":"5100002904","type":"CDM"},{"code":"0510","type":"RC"},{"code":"33274","type":"HCPCS"}],"standard_charges":[{"gross_charge":56372.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OSTEOPTHIC MANIPULATIE TREATMENT 1 TO 2 REGIONS","code_information":[{"code":"5300000000","type":"CDM"},{"code":"0530","type":"RC"},{"code":"98925","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI TEMPOROMANDIBULAR JOINT","code_information":[{"code":"6100000000","type":"CDM"},{"code":"0610","type":"RC"},{"code":"70336","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ORBIT FACE AND OR NECK WO CONTRAST MATERIAL","code_information":[{"code":"6100000001","type":"CDM"},{"code":"0610","type":"RC"},{"code":"70540","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ORBIT FACE AND NECK W CONTRAST MATERIAL","code_information":[{"code":"6100000002","type":"CDM"},{"code":"0610","type":"RC"},{"code":"70542","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ORBIT FACE AND NECK W WO CONTRAST MATERIAL","code_information":[{"code":"6100000003","type":"CDM"},{"code":"0610","type":"RC"},{"code":"70543","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA HEAD WO CONTRAST MATERIAL","code_information":[{"code":"6100000004","type":"CDM"},{"code":"0615","type":"RC"},{"code":"70544","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA HEAD W CONTRAST MATERIAL","code_information":[{"code":"6100000005","type":"CDM"},{"code":"0615","type":"RC"},{"code":"70545","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA HEAD W WO CONTRAST MATERIAL","code_information":[{"code":"6100000006","type":"CDM"},{"code":"0615","type":"RC"},{"code":"70546","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA NECK WO CONTRAST MATERIAL","code_information":[{"code":"6100000007","type":"CDM"},{"code":"0615","type":"RC"},{"code":"70547","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA NECK W CONTRAST MATERIAL","code_information":[{"code":"6100000008","type":"CDM"},{"code":"0615","type":"RC"},{"code":"70548","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA NECK W WO CONTRAST MATERIAL","code_information":[{"code":"6100000009","type":"CDM"},{"code":"0615","type":"RC"},{"code":"70549","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BRAIN BRAIN STEM WO CONTRAST MATERIAL","code_information":[{"code":"6100000010","type":"CDM"},{"code":"0611","type":"RC"},{"code":"70551","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BRAIN BRAIN STEM W CONTRAST MATERIAL","code_information":[{"code":"6100000011","type":"CDM"},{"code":"0611","type":"RC"},{"code":"70552","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BRAIN BRAIN STEM W WO CONTRAST MATERIAL","code_information":[{"code":"6100000012","type":"CDM"},{"code":"0611","type":"RC"},{"code":"70553","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI CHEST WO CONTRAST MATERIAL","code_information":[{"code":"6100000013","type":"CDM"},{"code":"0610","type":"RC"},{"code":"71550","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI CHEST W CONTRAST MATERIAL","code_information":[{"code":"6100000014","type":"CDM"},{"code":"0610","type":"RC"},{"code":"71551","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI CHEST W WO CONTRAST MATERIAL","code_information":[{"code":"6100000015","type":"CDM"},{"code":"0610","type":"RC"},{"code":"71552","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA CHEST W WO CONTRAST MATERIAL","code_information":[{"code":"6100000016","type":"CDM"},{"code":"0610","type":"RC"},{"code":"71555","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL CERVICAL WO CONTRAST MATERIAL","code_information":[{"code":"6100000017","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72141","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL CERVICAL W CONTRAST MATERIAL","code_information":[{"code":"6100000018","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72142","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL THORACIC WO CONTRAST MATERIAL","code_information":[{"code":"6100000019","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72146","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL THORACIC W CONTRAST MATERIAL","code_information":[{"code":"6100000020","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72147","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL LUMBAR WO CONTRAST MATERIAL","code_information":[{"code":"6100000021","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72148","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL LUMBAR W CONTRAST MATERIAL","code_information":[{"code":"6100000022","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72149","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL CERVICAL WO AND W CONTRAST MATERIAL","code_information":[{"code":"6100000023","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72156","type":"HCPCS"}],"standard_charges":[{"gross_charge":2645.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL THORACIC WO AND W CONTRAST MATERIAL","code_information":[{"code":"6100000024","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72157","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SPINAL CANAL LUMBAR WO AND W CONTRAST MATERIAL","code_information":[{"code":"6100000025","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72158","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA SPINAL CANAL W WO CONTRAST MATERIAL","code_information":[{"code":"6100000026","type":"CDM"},{"code":"0612","type":"RC"},{"code":"72159","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI PELVIS WO CONTRAST MATERIAL","code_information":[{"code":"6100000027","type":"CDM"},{"code":"0610","type":"RC"},{"code":"72195","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI PELVIS W CONTRAST MATERIAL","code_information":[{"code":"6100000028","type":"CDM"},{"code":"0610","type":"RC"},{"code":"72196","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI PELVIS W WO CONTRAST MATERIAL","code_information":[{"code":"6100000029","type":"CDM"},{"code":"0610","type":"RC"},{"code":"72197","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA PELVIS W WO CONTRAST MATERIAL","code_information":[{"code":"6100000030","type":"CDM"},{"code":"0610","type":"RC"},{"code":"72198","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI UPPER EXTR OTH THAN JOINT WO CONTRAST MATERIAL","code_information":[{"code":"6100000031","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73218","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI UPPER EXTR OTH THAN JOINT W CONTRAST MATERIAL","code_information":[{"code":"6100000032","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73219","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI UPPER EXTR OTHER THAN JOINT W WO CONTRAST","code_information":[{"code":"6100000033","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73220","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ANY JOINT UPPER EXT WO CONTRAST MATERIAL","code_information":[{"code":"6100000034","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73221","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ANY JOINT UPPER EXT W CONTRAST MATERIAL","code_information":[{"code":"6100000035","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73222","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ANY JOINT UPPER EXT W WO CONTRAST MATERIAL","code_information":[{"code":"6100000036","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73223","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA UPPER EXT W WO CONTRAST MATERIAL","code_information":[{"code":"6100000037","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73225","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI LOWER EXTR OTH THN JOINT WO CONTRAST MATERIAL","code_information":[{"code":"6100000038","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73718","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI LOWER EXTR OTH THN JOINT W CONTRAST MATERIAL","code_information":[{"code":"6100000039","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73719","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI LOWER EXTR OTH THN JOINT W WO CONTRAST MATERIAL","code_information":[{"code":"6100000040","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73720","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ANY JOINT LOWER EXT WO CONTRAST MATERIAL","code_information":[{"code":"6100000041","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73721","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ANY JOINT LOWER EXT W CONTRAST MATERIAL","code_information":[{"code":"6100000042","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73722","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ANY JOINT LOWER EXT W WO CONTRAST MATERIAL","code_information":[{"code":"6100000043","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73723","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA LOWER EXTR W WO CONTRAST MATERIAL","code_information":[{"code":"6100000044","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73725","type":"HCPCS"}],"standard_charges":[{"gross_charge":1624.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ABD WO CONTRAST MATERIAL","code_information":[{"code":"6100000045","type":"CDM"},{"code":"0610","type":"RC"},{"code":"74181","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ABD W CONTRAST MATERIAL","code_information":[{"code":"6100000046","type":"CDM"},{"code":"0610","type":"RC"},{"code":"74182","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI ABD W WO CONTRAST MATERIAL","code_information":[{"code":"6100000047","type":"CDM"},{"code":"0610","type":"RC"},{"code":"74183","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA ABD W WO CONTRAST MATERIAL","code_information":[{"code":"6100000048","type":"CDM"},{"code":"0610","type":"RC"},{"code":"74185","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 3D RENDERING W INTER AND POSTPROCESS SUPERVISION","code_information":[{"code":"6100000050","type":"CDM"},{"code":"0350","type":"RC"},{"code":"76376","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 3D RENDERING W INTER AND POSTPROCESS DIFF WORK STATION","code_information":[{"code":"6100000051","type":"CDM"},{"code":"0350","type":"RC"},{"code":"76377","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MR GUIDANCE NEEDLE PLACEMENT","code_information":[{"code":"6100000054","type":"CDM"},{"code":"0610","type":"RC"},{"code":"77021","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA CHEST W CONTRAST MATERIAL","code_information":[{"code":"6100000061","type":"CDM"},{"code":"0610","type":"RC"},{"code":"71555","type":"HCPCS"}],"standard_charges":[{"gross_charge":1328.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA CHEST WO CONTRAST MATERIAL","code_information":[{"code":"6100000062","type":"CDM"},{"code":"0610","type":"RC"},{"code":"71555","type":"HCPCS"}],"standard_charges":[{"gross_charge":1141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA LOWER EXT W CONTRAST MATERIAL","code_information":[{"code":"6100000065","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73725","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRA LOWER EXT WO CONTRAST MATERIAL","code_information":[{"code":"6100000066","type":"CDM"},{"code":"0610","type":"RC"},{"code":"73725","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST","code_information":[{"code":"6100000076","type":"CDM"},{"code":"0610","type":"RC"},{"code":"75557","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIAC MRI W/W/O CONTRAST W STRESS","code_information":[{"code":"6100000078","type":"CDM"},{"code":"0610","type":"RC"},{"code":"75563","type":"HCPCS"}],"standard_charges":[{"gross_charge":2672.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRCP WO CHOLANGIOPANCREATOGRAPHY","code_information":[{"code":"6100000081","type":"CDM"},{"code":"0610","type":"RC"},{"code":"74181","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRCP WO W CHOLANGIOPANCREATOGRAPHY","code_information":[{"code":"6100000082","type":"CDM"},{"code":"0610","type":"RC"},{"code":"74183","type":"HCPCS"}],"standard_charges":[{"gross_charge":6602.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MAGNETIC RESONANCE ELASTOGRAPHY","code_information":[{"code":"6100000083","type":"CDM"},{"code":"0610","type":"RC"},{"code":"76391","type":"HCPCS"}],"standard_charges":[{"gross_charge":21332.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL","code_information":[{"code":"6100000084","type":"CDM"},{"code":"0610","type":"RC"},{"code":"77046","type":"HCPCS"}],"standard_charges":[{"gross_charge":6314.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL","code_information":[{"code":"6100000085","type":"CDM"},{"code":"0610","type":"RC"},{"code":"77047","type":"HCPCS"}],"standard_charges":[{"gross_charge":6946.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BREAST WITHOUT&WITH CONTRAST W CAD BILATERAL","code_information":[{"code":"6100000087","type":"CDM"},{"code":"0610","type":"RC"},{"code":"77049","type":"HCPCS"}],"standard_charges":[{"gross_charge":9253.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CAD BREAST MRI WITH MD REVIEW FOR INTERP","code_information":[{"code":"6100000088","type":"CDM"},{"code":"0610","type":"RC"},{"code":"C8937","type":"HCPCS"}],"standard_charges":[{"gross_charge":500.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI WHOLE BODY W O CONTRAST","code_information":[{"code":"6100000100","type":"CDM"},{"code":"0610","type":"RC"},{"code":"76498","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI BONE MARROW STUDY","code_information":[{"code":"6101000000","type":"CDM"},{"code":"0610","type":"RC"},{"code":"77084","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC M.R.I.","code_information":[{"code":"6101000001","type":"CDM"},{"code":"0610","type":"RC"},{"code":"6101000001","type":"HCPCS"}],"standard_charges":[{"gross_charge":1123.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MRI SHIELDS","code_information":[{"code":"6101000002","type":"CDM"},{"code":"0610","type":"RC"},{"code":"6101000002","type":"HCPCS"}],"standard_charges":[{"gross_charge":507.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AMBULANCE SERVICES","code_information":[{"code":"6101000003","type":"CDM"},{"code":"0610","type":"RC"},{"code":"6101000003","type":"HCPCS"}],"standard_charges":[{"gross_charge":522.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 636 Q4101","code_information":[{"code":"6360000007","type":"CDM"},{"code":"0636","type":"RC"},{"code":"Q4101","type":"HCPCS"}],"standard_charges":[{"gross_charge":127.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 636 Q4116","code_information":[{"code":"6360000010","type":"CDM"},{"code":"0278","type":"RC"},{"code":"Q4116","type":"HCPCS"}],"standard_charges":[{"gross_charge":10593.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 636 Q4102","code_information":[{"code":"6360000011","type":"CDM"},{"code":"0636","type":"RC"},{"code":"Q4102","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KENALOG 10MG","code_information":[{"code":"6360000023","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J3301","type":"HCPCS"}],"standard_charges":[{"gross_charge":7.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BOTOX TYPE A PER UNIT INJ","code_information":[{"code":"6360000026","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J0585","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEPO PROVERA PER MG","code_information":[{"code":"6360000049","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J1050","type":"HCPCS"}],"standard_charges":[{"gross_charge":2.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEPARIN FLUSH PER 10 UNITS","code_information":[{"code":"6360000050","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J1642","type":"HCPCS"}],"standard_charges":[{"gross_charge":3.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC KETOROLAC TORADOL 15MG","code_information":[{"code":"6360000053","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J1885","type":"HCPCS"}],"standard_charges":[{"gross_charge":3.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSULIN INJECTION PER 5 U","code_information":[{"code":"6360000073","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J1815","type":"HCPCS"}],"standard_charges":[{"gross_charge":2.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BOTOX B MYOBLOC PER 100 UN","code_information":[{"code":"6360000086","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J0587","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RX PNEUMOCOCCAL POLY VAC","code_information":[{"code":"6360000137","type":"CDM"},{"code":"0636","type":"RC"},{"code":"90732","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RX PNEUMOCOCCL VACCINE (PREVNAR13)","code_information":[{"code":"6360000142","type":"CDM"},{"code":"0636","type":"RC"},{"code":"90670","type":"HCPCS"}],"standard_charges":[{"gross_charge":565.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REV CODE 636 Q4128","code_information":[{"code":"6360000165","type":"CDM"},{"code":"0636","type":"RC"},{"code":"Q4128","type":"HCPCS"}],"standard_charges":[{"gross_charge":6825.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PURAPLY 1 SQ CM","code_information":[{"code":"6360000190","type":"CDM"},{"code":"0636","type":"RC"},{"code":"Q4195","type":"HCPCS"}],"standard_charges":[{"gross_charge":158.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PURAPLY AM 1 SQ CM","code_information":[{"code":"6360000191","type":"CDM"},{"code":"0636","type":"RC"},{"code":"Q4196","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRAUT COPPER CONTRACEPTIVE","code_information":[{"code":"6360000418","type":"CDM"},{"code":"0636","type":"RC"},{"code":"J7300","type":"HCPCS"}],"standard_charges":[{"gross_charge":1794.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RECOVERY PHASE I PACU","code_information":[{"code":"7100000000","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":295.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RECOVERY PHASE 2","code_information":[{"code":"7100000002","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000002","type":"HCPCS"}],"standard_charges":[{"gross_charge":524.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RECOVERY PHASE 1 - 1ST 15 MINS","code_information":[{"code":"7100000007","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000007","type":"HCPCS"}],"standard_charges":[{"gross_charge":332.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RECOVERY PHASE 1 - EA ADD 15 MINS","code_information":[{"code":"7100000008","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000008","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RECOVERY PHASE 2 - 1ST 15 MINS","code_information":[{"code":"7100000009","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000009","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RECOVERY PHASE 2 - EA ADD 15 MINS","code_information":[{"code":"7100000010","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000010","type":"HCPCS"}],"standard_charges":[{"gross_charge":93.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXTENDED RECOVERY - PER MIN","code_information":[{"code":"7100000011","type":"CDM"},{"code":"0710","type":"RC"},{"code":"7100000011","type":"HCPCS"}],"standard_charges":[{"gross_charge":6.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT CERVICAL DILATOR SEP PROC","code_information":[{"code":"7200000000","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59200","type":"HCPCS"}],"standard_charges":[{"gross_charge":1711.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXTERNAL CEPHALIC VERSION W WO TOCOLYSIS","code_information":[{"code":"7200000001","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59412","type":"HCPCS"}],"standard_charges":[{"gross_charge":6533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FETAL MONITORING LABOR PHYS WRITTEN RPT","code_information":[{"code":"7200000002","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59050","type":"HCPCS"}],"standard_charges":[{"gross_charge":1659.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CURETTAGE POSTPARTUM","code_information":[{"code":"7200000003","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59160","type":"HCPCS"}],"standard_charges":[{"gross_charge":4632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EPISIOTOMY VAG REPAIR OTH THAN ATTENDING","code_information":[{"code":"7200000004","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59300","type":"HCPCS"}],"standard_charges":[{"gross_charge":4469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DELIVERY OF PLACENTA SEPARATE PROC","code_information":[{"code":"7200000005","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59414","type":"HCPCS"}],"standard_charges":[{"gross_charge":8229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSTETRIC CARE VAGINAL DELIVERY AND POSTPARTUM","code_information":[{"code":"7200000006","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59410","type":"HCPCS"}],"standard_charges":[{"gross_charge":2999.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL OF CERCLAGE","code_information":[{"code":"7200000007","type":"CDM"},{"code":"0720","type":"RC"},{"code":"59871","type":"HCPCS"}],"standard_charges":[{"gross_charge":5585.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OB SURGERY LEVEL 3 - 1ST 15 MINS","code_information":[{"code":"7200000009","type":"CDM"},{"code":"0720","type":"RC"}],"standard_charges":[{"gross_charge":702.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OB SURGERY LEVEL 3 - EA ADD 15 MINS","code_information":[{"code":"7200000010","type":"CDM"},{"code":"0720","type":"RC"}],"standard_charges":[{"gross_charge":468.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSTETRIC CARE CESAREAN DELIVERY AND POSTPARTUM","code_information":[{"code":"7220000000","type":"CDM"},{"code":"0722","type":"RC"},{"code":"59515","type":"HCPCS"}],"standard_charges":[{"gross_charge":1444.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VAGINAL LABOR & DELIVERY LEVEL 1","code_information":[{"code":"7220000002","type":"CDM"},{"code":"0722","type":"RC"}],"standard_charges":[{"gross_charge":2813.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VAGINAL LABOR & DELIVERY LEVEL 2","code_information":[{"code":"7220000003","type":"CDM"},{"code":"0722","type":"RC"}],"standard_charges":[{"gross_charge":3375.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VAGINAL LABOR & DELIVERY LEVEL 3","code_information":[{"code":"7220000004","type":"CDM"},{"code":"0722","type":"RC"}],"standard_charges":[{"gross_charge":4050.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VAG DELIV ONLY,PREV C-SECTN","code_information":[{"code":"7220000005","type":"CDM"},{"code":"0722","type":"RC"},{"code":"59612","type":"HCPCS"}],"standard_charges":[{"gross_charge":2070.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSTETRIC CARE VAGINAL DELIVERY","code_information":[{"code":"7240000000","type":"CDM"},{"code":"0724","type":"RC"},{"code":"59400","type":"HCPCS"}],"standard_charges":[{"gross_charge":6341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANTEPARTUM CARE 4 TO 6 VISITS","code_information":[{"code":"7240000001","type":"CDM"},{"code":"0724","type":"RC"},{"code":"59425","type":"HCPCS"}],"standard_charges":[{"gross_charge":903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANTEPARTUM CARE 7 OR MORE VISITS","code_information":[{"code":"7240000002","type":"CDM"},{"code":"0724","type":"RC"},{"code":"59426","type":"HCPCS"}],"standard_charges":[{"gross_charge":1755.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRENATAL DELIVERY & POST PARTUM @ NSBC","code_information":[{"code":"7240000004","type":"CDM"},{"code":"0724","type":"RC"},{"code":"59400","type":"HCPCS"}],"standard_charges":[{"gross_charge":6173.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRENATAL ONLY @ NSBC WITH PLANNED HOSPITAL DELIVERY BY MIDWIFE","code_information":[{"code":"7240000006","type":"CDM"},{"code":"0724","type":"RC"},{"code":"59426","type":"HCPCS"}],"standard_charges":[{"gross_charge":1755.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRENATAL VISITS (7 OR MORE)","code_information":[{"code":"7240000007","type":"CDM"},{"code":"0724","type":"RC"},{"code":"59426","type":"HCPCS"}],"standard_charges":[{"gross_charge":1755.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ROUTINE ECG TRACING WO INTER AND RPT","code_information":[{"code":"7300000000","type":"CDM"},{"code":"0730","type":"RC"},{"code":"93005","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RHYTHM ECG TRACTIONE WO INTER","code_information":[{"code":"7300000002","type":"CDM"},{"code":"0730","type":"RC"},{"code":"93041","type":"HCPCS"}],"standard_charges":[{"gross_charge":195.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGNAL AVERAGED ECG","code_information":[{"code":"7300000003","type":"CDM"},{"code":"0730","type":"RC"},{"code":"93278","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXTERNAL ECG REC>48HR<7D RECORDING","code_information":[{"code":"7300000009","type":"CDM"},{"code":"0731","type":"RC"},{"code":"93242","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXTERNAL ECG REC>7D<15D RECORDING","code_information":[{"code":"7300000010","type":"CDM"},{"code":"0731","type":"RC"},{"code":"93246","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECG ROUTINE ECG W/LEAST 12 LDS W/I&R","code_information":[{"code":"7300000014","type":"CDM"},{"code":"0730","type":"RC"},{"code":"93000","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECG MONITOR 24 HR REC HOOK UP","code_information":[{"code":"7310000000","type":"CDM"},{"code":"0731","type":"RC"},{"code":"93225","type":"HCPCS"}],"standard_charges":[{"gross_charge":381.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECG MONITOR 24 HRS SCAN ANALYSIS","code_information":[{"code":"7310000001","type":"CDM"},{"code":"0731","type":"RC"},{"code":"93226","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRESYMPTOM EVENT HOOK UP","code_information":[{"code":"7310000002","type":"CDM"},{"code":"0731","type":"RC"},{"code":"93270","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRESYMPTOM EVENT RECORDER","code_information":[{"code":"7310000003","type":"CDM"},{"code":"0731","type":"RC"},{"code":"93271","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG EXTEND MONITOR MORE THAN 60 MIN","code_information":[{"code":"7400000000","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95813","type":"HCPCS"}],"standard_charges":[{"gross_charge":1269.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG INCL REC AWAKE AND DROWSY","code_information":[{"code":"7400000001","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95816","type":"HCPCS"}],"standard_charges":[{"gross_charge":1013.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG INCL REC AWAKE AND ASLEEP","code_information":[{"code":"7400000002","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95819","type":"HCPCS"}],"standard_charges":[{"gross_charge":1013.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECTROENCEPHALOGRAM EXTEND MONITORING 41-60 MIN","code_information":[{"code":"7400000007","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95812","type":"HCPCS"}],"standard_charges":[{"gross_charge":1269.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG COMA SLEEP RECORD ONLY","code_information":[{"code":"7400000008","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95822","type":"HCPCS"}],"standard_charges":[{"gross_charge":755.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG CONT REC W VIDEO BY TECH MIN 8 CHANNELS","code_information":[{"code":"7400000011","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95700","type":"HCPCS"}],"standard_charges":[{"gross_charge":801.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG W O VID BY TECH EA INCR 12-26HR UNMONITORED","code_information":[{"code":"7400000015","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95708","type":"HCPCS"}],"standard_charges":[{"gross_charge":1713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG W O VID TECH EA INCR 12-26 HR CONT R-T MNTR","code_information":[{"code":"7400000017","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95710","type":"HCPCS"}],"standard_charges":[{"gross_charge":1713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VEEG BY TECH 2-12 HR INTERMITTENT MONITORING","code_information":[{"code":"7400000019","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95712","type":"HCPCS"}],"standard_charges":[{"gross_charge":990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED","code_information":[{"code":"7400000021","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95714","type":"HCPCS"}],"standard_charges":[{"gross_charge":1713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR","code_information":[{"code":"7400000022","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95715","type":"HCPCS"}],"standard_charges":[{"gross_charge":1713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR","code_information":[{"code":"7400000023","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95716","type":"HCPCS"}],"standard_charges":[{"gross_charge":3308.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ECOG IMPLANTED BRAIN NPGT W/REC I&R <30 DAYS","code_information":[{"code":"7400000026","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95836","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EEG CEREBRAL DEATH EVAL","code_information":[{"code":"7401000003","type":"CDM"},{"code":"0740","type":"RC"},{"code":"95824","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY RIGID W SUBMUCOSAL INJ","code_information":[{"code":"7500000001","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43192","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX TRANSORAL DIAG COLLECT SPECIMEN","code_information":[{"code":"7500000007","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43200","type":"HCPCS"}],"standard_charges":[{"gross_charge":1447.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY W SUBMUCOSAL INJ","code_information":[{"code":"7500000008","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43201","type":"HCPCS"}],"standard_charges":[{"gross_charge":5629.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX TRANSORAL BIOPSY","code_information":[{"code":"7500000009","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43202","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX TRANSORAL BAND LIGATION","code_information":[{"code":"7500000010","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43205","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX TRANSORAL DILATION UNDER 30 MM","code_information":[{"code":"7500000012","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43212","type":"HCPCS"}],"standard_charges":[{"gross_charge":18483.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX TRANSO W RMVL FB","code_information":[{"code":"7500000015","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43215","type":"HCPCS"}],"standard_charges":[{"gross_charge":6665.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX TRANSORAL DILATION","code_information":[{"code":"7500000017","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43220","type":"HCPCS"}],"standard_charges":[{"gross_charge":6862.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FLEX W ENDO US","code_information":[{"code":"7500000020","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43231","type":"HCPCS"}],"standard_charges":[{"gross_charge":3408.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI FLEX DILATION","code_information":[{"code":"7500000021","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43233","type":"HCPCS"}],"standard_charges":[{"gross_charge":1849.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO DIAG BRUSH WASH","code_information":[{"code":"7500000022","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43235","type":"HCPCS"}],"standard_charges":[{"gross_charge":1610.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO W SUBMUCOSAL INJ","code_information":[{"code":"7500000023","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43236","type":"HCPCS"}],"standard_charges":[{"gross_charge":1610.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO W US EXAM","code_information":[{"code":"7500000024","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43237","type":"HCPCS"}],"standard_charges":[{"gross_charge":1736.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO W TRANSENDO","code_information":[{"code":"7500000025","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43238","type":"HCPCS"}],"standard_charges":[{"gross_charge":1736.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO BIOPSY","code_information":[{"code":"7500000026","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43239","type":"HCPCS"}],"standard_charges":[{"gross_charge":1658.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO TRANSMURAL DRAIN","code_information":[{"code":"7500000027","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43240","type":"HCPCS"}],"standard_charges":[{"gross_charge":18483.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO TRANSENDO TUBE","code_information":[{"code":"7500000028","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43241","type":"HCPCS"}],"standard_charges":[{"gross_charge":3419.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO ASPIRATION","code_information":[{"code":"7500000029","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43242","type":"HCPCS"}],"standard_charges":[{"gross_charge":3668.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO INJ SCLEROSIS","code_information":[{"code":"7500000030","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43243","type":"HCPCS"}],"standard_charges":[{"gross_charge":3467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO BAND LIGATION","code_information":[{"code":"7500000031","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43244","type":"HCPCS"}],"standard_charges":[{"gross_charge":3309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO DILAT GASTR OUT","code_information":[{"code":"7500000032","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43245","type":"HCPCS"}],"standard_charges":[{"gross_charge":3309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO PLACE PERC TUBE","code_information":[{"code":"7500000033","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43246","type":"HCPCS"}],"standard_charges":[{"gross_charge":3306.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD FLEX TRANSO W FOREIGN BODY","code_information":[{"code":"7500000034","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43247","type":"HCPCS"}],"standard_charges":[{"gross_charge":3309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO W INSERTION OF GUIDE WIRE","code_information":[{"code":"7500000035","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43248","type":"HCPCS"}],"standard_charges":[{"gross_charge":3309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO BALLOON DILAT","code_information":[{"code":"7500000036","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43249","type":"HCPCS"}],"standard_charges":[{"gross_charge":1675.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD FLEX TRANSO W W RMVL TMR POLYP LES HOT BX FORC","code_information":[{"code":"7500000037","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43250","type":"HCPCS"}],"standard_charges":[{"gross_charge":3467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO REMTUM SNARE","code_information":[{"code":"7500000038","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43251","type":"HCPCS"}],"standard_charges":[{"gross_charge":3309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI FLEX TRANSORAL INJ","code_information":[{"code":"7500000039","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43253","type":"HCPCS"}],"standard_charges":[{"gross_charge":3441.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI FLEX TRANSORAL RESECTION","code_information":[{"code":"7500000040","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43254","type":"HCPCS"}],"standard_charges":[{"gross_charge":2588.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO CTRL BLEEDING","code_information":[{"code":"7500000041","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43255","type":"HCPCS"}],"standard_charges":[{"gross_charge":3309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPPER GI ENDO US","code_information":[{"code":"7500000042","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43259","type":"HCPCS"}],"standard_charges":[{"gross_charge":3668.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP DIAGNOSTIC","code_information":[{"code":"7500000043","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43260","type":"HCPCS"}],"standard_charges":[{"gross_charge":3467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP W BIOPSY SINGLE OR MULTIPLE","code_information":[{"code":"7500000044","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43261","type":"HCPCS"}],"standard_charges":[{"gross_charge":3469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP W SPHINCTEROTOMY PAPILLOTOMY","code_information":[{"code":"7500000045","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43262","type":"HCPCS"}],"standard_charges":[{"gross_charge":4920.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP REMOVAL CALCULUS DUCTS","code_information":[{"code":"7500000047","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43264","type":"HCPCS"}],"standard_charges":[{"gross_charge":4920.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP W LITHOTRIPSY CALCULUS","code_information":[{"code":"7500000048","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43265","type":"HCPCS"}],"standard_charges":[{"gross_charge":3366.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOGASTRODUODENOSCOPY FLEX TRANSORAL STENT","code_information":[{"code":"7500000049","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43266","type":"HCPCS"}],"standard_charges":[{"gross_charge":5100.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP FLEX TRANSORAL ABLATION","code_information":[{"code":"7500000052","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43270","type":"HCPCS"}],"standard_charges":[{"gross_charge":4880.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSCOPIC PAPILLA CANNULATION BILE PANCREATIC","code_information":[{"code":"7500000053","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43273","type":"HCPCS"}],"standard_charges":[{"gross_charge":5175.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP W PLACEMENT BILIARY STENT","code_information":[{"code":"7500000054","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43274","type":"HCPCS"}],"standard_charges":[{"gross_charge":3469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP W REMOVAL FB","code_information":[{"code":"7500000055","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43275","type":"HCPCS"}],"standard_charges":[{"gross_charge":3469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP REMOVAL AND CHANGE STENTS","code_information":[{"code":"7500000056","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43276","type":"HCPCS"}],"standard_charges":[{"gross_charge":4082.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ERCP W TRANS ENDOSCOPIC BALLOON","code_information":[{"code":"7500000057","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43277","type":"HCPCS"}],"standard_charges":[{"gross_charge":4061.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSCOPY UPPER SMALL INTESTINE","code_information":[{"code":"7500000059","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44360","type":"HCPCS"}],"standard_charges":[{"gross_charge":5212.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL INTEST ENDO W BIOPSY","code_information":[{"code":"7500000060","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44361","type":"HCPCS"}],"standard_charges":[{"gross_charge":5229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL INTEST ENDO CONTRAST BLEED","code_information":[{"code":"7500000061","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44366","type":"HCPCS"}],"standard_charges":[{"gross_charge":5302.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL INTEST ENDO W ABLATION TUMORS","code_information":[{"code":"7500000062","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44369","type":"HCPCS"}],"standard_charges":[{"gross_charge":10495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL INTEST ENDO DUOD ILEUM","code_information":[{"code":"7500000064","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44376","type":"HCPCS"}],"standard_charges":[{"gross_charge":2463.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL BOWEL ENDOS W BIOPSY","code_information":[{"code":"7500000065","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44377","type":"HCPCS"}],"standard_charges":[{"gross_charge":5302.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMALL BOWEL ENDOS W CONTROL OF BLEEDING","code_information":[{"code":"7500000066","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44378","type":"HCPCS"}],"standard_charges":[{"gross_charge":10495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ILEOSCOPY THRU STOMA DX W SPEC COLL WHEN PRFMD","code_information":[{"code":"7500000067","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44380","type":"HCPCS"}],"standard_charges":[{"gross_charge":2217.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ILEOSCOPY STOMA W BIOPSY","code_information":[{"code":"7500000068","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44382","type":"HCPCS"}],"standard_charges":[{"gross_charge":2198.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA DX W SPEC COLL WHEN PRFMD","code_information":[{"code":"7500000069","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44388","type":"HCPCS"}],"standard_charges":[{"gross_charge":2298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA BIOPSY","code_information":[{"code":"7500000070","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44389","type":"HCPCS"}],"standard_charges":[{"gross_charge":2083.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA W CONTROL OF BLEEDING","code_information":[{"code":"7500000071","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44391","type":"HCPCS"}],"standard_charges":[{"gross_charge":3661.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA TUMOR SNARE","code_information":[{"code":"7500000074","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44394","type":"HCPCS"}],"standard_charges":[{"gross_charge":4809.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOS SMALL INTEST OTHER","code_information":[{"code":"7500000077","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44799","type":"HCPCS"}],"standard_charges":[{"gross_charge":7424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FECAL TRANSPLANT","code_information":[{"code":"7500000079","type":"CDM"},{"code":"0750","type":"RC"},{"code":"G0455","type":"HCPCS"}],"standard_charges":[{"gross_charge":1205.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROCTOSGMDSC RIGID DIAG W WO SPEC COLL BR SEP PROC","code_information":[{"code":"7500000081","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45300","type":"HCPCS"}],"standard_charges":[{"gross_charge":2036.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PROCTOSGMDSC RIGID CONTROL OF BLEEDING","code_information":[{"code":"7500000084","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45317","type":"HCPCS"}],"standard_charges":[{"gross_charge":3537.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX DX W SPEC COLL WHEN PFRMD","code_information":[{"code":"7500000085","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45330","type":"HCPCS"}],"standard_charges":[{"gross_charge":2147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W BIOPSY SINGLE MULTIPLE","code_information":[{"code":"7500000086","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45331","type":"HCPCS"}],"standard_charges":[{"gross_charge":2101.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W RMVL FOREIGN BODY","code_information":[{"code":"7500000087","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45332","type":"HCPCS"}],"standard_charges":[{"gross_charge":1952.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W RMVL TMR POLYP LES HOT BX FORCEPS","code_information":[{"code":"7500000088","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45333","type":"HCPCS"}],"standard_charges":[{"gross_charge":1353.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W CONTROL OF BLEEDING","code_information":[{"code":"7500000089","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45334","type":"HCPCS"}],"standard_charges":[{"gross_charge":2083.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W SUBMUCOSAL INJ","code_information":[{"code":"7500000090","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45335","type":"HCPCS"}],"standard_charges":[{"gross_charge":1222.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX DECOMP INC PLCMT OF DECOMP TUBE","code_information":[{"code":"7500000091","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45337","type":"HCPCS"}],"standard_charges":[{"gross_charge":2229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX REMOVAL TUMOR SNARE","code_information":[{"code":"7500000092","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45338","type":"HCPCS"}],"standard_charges":[{"gross_charge":2108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W TRANSENDO BALLOON DIL","code_information":[{"code":"7500000094","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45340","type":"HCPCS"}],"standard_charges":[{"gross_charge":2108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX W ENDO US","code_information":[{"code":"7500000095","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45341","type":"HCPCS"}],"standard_charges":[{"gross_charge":2108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOID FLEX TRANSEND US","code_information":[{"code":"7500000096","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45342","type":"HCPCS"}],"standard_charges":[{"gross_charge":2370.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX DX W SPEC COLL WHEN PFRMD","code_information":[{"code":"7500000098","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45378","type":"HCPCS"}],"standard_charges":[{"gross_charge":2147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY  FLEX W RMVL FOREIGN BODY","code_information":[{"code":"7500000099","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45379","type":"HCPCS"}],"standard_charges":[{"gross_charge":2229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W BX SGL OR MULT","code_information":[{"code":"7500000100","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45380","type":"HCPCS"}],"standard_charges":[{"gross_charge":2294.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W DIRECTED SUBMUCOSAL INJ","code_information":[{"code":"7500000101","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45381","type":"HCPCS"}],"standard_charges":[{"gross_charge":2147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W CONTROL OF BLEEDING","code_information":[{"code":"7500000102","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45382","type":"HCPCS"}],"standard_charges":[{"gross_charge":2101.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W RMVL TMR POLYP LES HOT BX FORCEPS","code_information":[{"code":"7500000104","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45384","type":"HCPCS"}],"standard_charges":[{"gross_charge":2147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W RMVL TMR POLYP LES SNARE TECH","code_information":[{"code":"7500000105","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45385","type":"HCPCS"}],"standard_charges":[{"gross_charge":2147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W TRANSENDO BALLON DILATION","code_information":[{"code":"7500000106","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45386","type":"HCPCS"}],"standard_charges":[{"gross_charge":2294.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W ENDO US LMTD RTM SIGM DC TC AC CECUM","code_information":[{"code":"7500000108","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45391","type":"HCPCS"}],"standard_charges":[{"gross_charge":2101.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM ANAL SETON OTHER MARKER","code_information":[{"code":"7500000110","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46030","type":"HCPCS"}],"standard_charges":[{"gross_charge":3537.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN ISCHIORECTAL AND OR PERIRECTAL ABS SEP PROC","code_information":[{"code":"7500000111","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46040","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS AND DRAIN PERIANAL ABSCESS SUPERFICIAL","code_information":[{"code":"7500000112","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46050","type":"HCPCS"}],"standard_charges":[{"gross_charge":1037.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INCIS THROMBOSED HEMORRHOID EXTERNAL","code_information":[{"code":"7500000114","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46083","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS","code_information":[{"code":"7500000115","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46221","type":"HCPCS"}],"standard_charges":[{"gross_charge":1632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEMORRHOIDECTOMY INTERN AND EXTERN SING COLUMN GRP","code_information":[{"code":"7500000117","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46255","type":"HCPCS"}],"standard_charges":[{"gross_charge":8515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC THROMBOSED HEMORRHOID EXTERNAL","code_information":[{"code":"7500000119","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46320","type":"HCPCS"}],"standard_charges":[{"gross_charge":3678.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANOSCOPY DX W SPEC COLL WHEN PRFMD","code_information":[{"code":"7500000121","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46600","type":"HCPCS"}],"standard_charges":[{"gross_charge":673.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANOSCOPY W DILATION","code_information":[{"code":"7500000122","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46604","type":"HCPCS"}],"standard_charges":[{"gross_charge":2418.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANOSCOPY W BIOPSY SINGLE MULTIPLE","code_information":[{"code":"7500000123","type":"CDM"},{"code":"0750","type":"RC"},{"code":"46606","type":"HCPCS"}],"standard_charges":[{"gross_charge":3661.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGEAL MOTILITY STUDY","code_information":[{"code":"7500000127","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91010","type":"HCPCS"}],"standard_charges":[{"gross_charge":1201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGUS GASTRO REFLUX NASAL CATH","code_information":[{"code":"7500000128","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91034","type":"HCPCS"}],"standard_charges":[{"gross_charge":960.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGUS GASTRO REFLUX W ELECTRODE","code_information":[{"code":"7500000129","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91035","type":"HCPCS"}],"standard_charges":[{"gross_charge":1713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BREATH HYDROGEN ANALYSIS","code_information":[{"code":"7500000131","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91065","type":"HCPCS"}],"standard_charges":[{"gross_charge":539.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC M2A CAPSULE ENDO","code_information":[{"code":"7500000132","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91110","type":"HCPCS"}],"standard_charges":[{"gross_charge":3708.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANCER SCREEN FLEX SIGMOID","code_information":[{"code":"7500000134","type":"CDM"},{"code":"0750","type":"RC"},{"code":"G0104","type":"HCPCS"}],"standard_charges":[{"gross_charge":1994.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANCER SCREEN COLONOSCOPY","code_information":[{"code":"7500000135","type":"CDM"},{"code":"0750","type":"RC"},{"code":"G0105","type":"HCPCS"}],"standard_charges":[{"gross_charge":2147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANCER SCREEN COLORECTAL NOT HIGH RISK","code_information":[{"code":"7500000136","type":"CDM"},{"code":"0750","type":"RC"},{"code":"G0121","type":"HCPCS"}],"standard_charges":[{"gross_charge":2132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GASTROINTESTINAL TRACT IMAGING ESOPHAGUS W/I&R","code_information":[{"code":"7500000139","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91111","type":"HCPCS"}],"standard_charges":[{"gross_charge":3095.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANAL PRESSURE RECORD","code_information":[{"code":"7500000140","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91122","type":"HCPCS"}],"standard_charges":[{"gross_charge":691.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOP W CNTRL BLEEDING","code_information":[{"code":"7500000145","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43227","type":"HCPCS"}],"standard_charges":[{"gross_charge":3262.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCOPY FINE NEEDL BX US GUIDE","code_information":[{"code":"7500000146","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43232","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOS ENTEROSC PAST 2ND PRTN W REM FB","code_information":[{"code":"7500000149","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44363","type":"HCPCS"}],"standard_charges":[{"gross_charge":5691.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SB SCOPE PLACE PERCUT JEJUN TUBE","code_information":[{"code":"7500000151","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44372","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGOSCP RIG TRANSOR HYPOPHARYNX CRV ESOPH","code_information":[{"code":"7500000153","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43180","type":"HCPCS"}],"standard_charges":[{"gross_charge":11372.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ILEOSCOPY STOMA W BALLOON DIL","code_information":[{"code":"7500000154","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44381","type":"HCPCS"}],"standard_charges":[{"gross_charge":10141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA W ENDOSC STENT PLCMT","code_information":[{"code":"7500000157","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44402","type":"HCPCS"}],"standard_charges":[{"gross_charge":17858.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ","code_information":[{"code":"7500000158","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44403","type":"HCPCS"}],"standard_charges":[{"gross_charge":3661.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY STOMA W/BALLOON DILATION","code_information":[{"code":"7500000160","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44405","type":"HCPCS"}],"standard_charges":[{"gross_charge":3661.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOIDOSCOPY FLX ABLATION TUMOR POLYP/OTH LES","code_information":[{"code":"7500000164","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45346","type":"HCPCS"}],"standard_charges":[{"gross_charge":2108.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SGMDSC FLX WITH ENDOS MUCOSAL RESECTION","code_information":[{"code":"7500000166","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45349","type":"HCPCS"}],"standard_charges":[{"gross_charge":3697.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S)","code_information":[{"code":"7500000167","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45350","type":"HCPCS"}],"standard_charges":[{"gross_charge":3491.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLX ABLATION TUMOR POLYP/OTHER LES","code_information":[{"code":"7500000168","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45388","type":"HCPCS"}],"standard_charges":[{"gross_charge":3492.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLX WITH ENDOS STENT PLACEMENT","code_information":[{"code":"7500000169","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45389","type":"HCPCS"}],"standard_charges":[{"gross_charge":8116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLX W ENDOS MUCOSAL RESECTION","code_information":[{"code":"7500000170","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45390","type":"HCPCS"}],"standard_charges":[{"gross_charge":2298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEXIBLE WITH DECOMPRESSION","code_information":[{"code":"7500000171","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45393","type":"HCPCS"}],"standard_charges":[{"gross_charge":5115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEXI W BAND LIGATION S","code_information":[{"code":"7500000172","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45398","type":"HCPCS"}],"standard_charges":[{"gross_charge":3661.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPR GI W OPTICAL ENDOMICROSCOPY","code_information":[{"code":"7500000180","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43252","type":"HCPCS"}],"standard_charges":[{"gross_charge":7167.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY FLEX W/ULTRASOUND GUIDE OR NEEDLE ASP/BIO","code_information":[{"code":"7500000181","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45392","type":"HCPCS"}],"standard_charges":[{"gross_charge":2229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CLOSURE OF GASTROSTOMY SURGICAL","code_information":[{"code":"7500000183","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43870","type":"HCPCS"}],"standard_charges":[{"gross_charge":11813.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GI TRANSIT AND PRES MEAS WIRELESS CAPSULE W/INTERP","code_information":[{"code":"7500000184","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91112","type":"HCPCS"}],"standard_charges":[{"gross_charge":2341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD W/VACUUM SPONGE THERAPY","code_information":[{"code":"7500000185","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43999","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RETROGRADE SINGLE BALLOON ENTEROSCOPY","code_information":[{"code":"7500000187","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44799","type":"HCPCS"}],"standard_charges":[{"gross_charge":7424.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC POUCHOSCOPY W/DILATION","code_information":[{"code":"7500000190","type":"CDM"},{"code":"0750","type":"RC"},{"code":"44799","type":"HCPCS"}],"standard_charges":[{"gross_charge":1838.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC G POEM GASTRIC PER ORAL ENDO MYOTOMY","code_information":[{"code":"7500000191","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43499","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY WITH CHROMOSCOPY","code_information":[{"code":"7500000192","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45399","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ESOPHAGUS SURG PROCEDURE UNLISTED","code_information":[{"code":"7500000193","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43499","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EUS GUIDED GASTROGASTROSTOMY OR GASTROJEJUNOSTOMY","code_information":[{"code":"7500000194","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43999","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLEXIBLE SIGMOIDOSCOPY WITH DILATION","code_information":[{"code":"7500000195","type":"CDM"},{"code":"0750","type":"RC"},{"code":"45399","type":"HCPCS"}],"standard_charges":[{"gross_charge":2831.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD W DILATION OF ESOPHAGUS (ANY METHOD)","code_information":[{"code":"7500000201","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43499","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD W/FISTULA CLOSING","code_information":[{"code":"7500000202","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43999","type":"HCPCS"}],"standard_charges":[{"gross_charge":2911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSORAL LOWER ESOPHAGEAL MYOTOMY","code_information":[{"code":"7500000209","type":"CDM"},{"code":"0750","type":"RC"},{"code":"43497","type":"HCPCS"}],"standard_charges":[{"gross_charge":18483.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GI TRACT IMAGING INTRALUMINAL COLON I&R","code_information":[{"code":"7500000212","type":"CDM"},{"code":"0750","type":"RC"},{"code":"91113","type":"HCPCS"}],"standard_charges":[{"gross_charge":2936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD FLEXIBLE TRANSNASAL DX W/COLLJ SPEC BRUSH/WASH","code_information":[{"code":"7500000215","type":"CDM"},{"code":"0750","type":"RC"},{"code":"0652T","type":"HCPCS"}],"standard_charges":[{"gross_charge":6758.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD FLEXIBLE TRANSNASAL W/BIOPSY SINGLE/MULTIPLE","code_information":[{"code":"7500000216","type":"CDM"},{"code":"0750","type":"RC"},{"code":"0653T","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EGD FLEXIBLE TRANSNASAL W/INSJ INTRAL TUBE/CATH","code_information":[{"code":"7500000217","type":"CDM"},{"code":"0750","type":"RC"},{"code":"0654T","type":"HCPCS"}],"standard_charges":[{"gross_charge":11813.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VULVECTOMY SIMPLE PARTIAL","code_information":[{"code":"7500000233","type":"CDM"},{"code":"0750","type":"RC"},{"code":"56620","type":"HCPCS"}],"standard_charges":[{"gross_charge":9873.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOSCOPIC OUTLET REDUCTION, GASTRIC POUCH APPLICATION, WITH ENDOSCOPY AND INTRALUMINAL TUBE INSERTION, IF PERFORMED, INCLUDING ALL SYSTEM AND TISSUE ANCHORING COMPONENTS","code_information":[{"code":"7500000246","type":"CDM"},{"code":"0750","type":"RC"},{"code":"C9785","type":"HCPCS"}],"standard_charges":[{"gross_charge":37092.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT NEW OR REPL PRM PACEMAKR W TRANS ELTRD ATRIAL","code_information":[{"code":"7610000002","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33206","type":"HCPCS"}],"standard_charges":[{"gross_charge":32495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT NEW OR REPL PRM PACEMAKER W TRANSV ELTRD VENT","code_information":[{"code":"7610000003","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33207","type":"HCPCS"}],"standard_charges":[{"gross_charge":22930.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT NEW OR RPLA PRM PM W TRANSV ELTRD ATRIAL AND VENT","code_information":[{"code":"7610000004","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33208","type":"HCPCS"}],"standard_charges":[{"gross_charge":27611.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT OR REPL TEMP TRANSVNS 1 CHMBR ELTRD PM CATH","code_information":[{"code":"7610000005","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33210","type":"HCPCS"}],"standard_charges":[{"gross_charge":16416.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC UPGRADE IMPLANTED PACEMAKER SYS CONVERSION","code_information":[{"code":"7610000006","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33214","type":"HCPCS"}],"standard_charges":[{"gross_charge":31396.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPOS PREV IMPLANTED TRANSVENOUS PACEMAKER","code_information":[{"code":"7610000007","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33215","type":"HCPCS"}],"standard_charges":[{"gross_charge":11214.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INS 1 TRVEN ELTRD PERM PCM OR IMPLTBL DFB","code_information":[{"code":"7610000008","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33216","type":"HCPCS"}],"standard_charges":[{"gross_charge":29485.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT PACEMAKER PULSE GEN ONLY W EXIST MULT LEADS","code_information":[{"code":"7610000010","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33221","type":"HCPCS"}],"standard_charges":[{"gross_charge":59215.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM PERM PM PULSE GEN W REPL PLSE GEN SINGLE LEAD","code_information":[{"code":"7610000016","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33227","type":"HCPCS"}],"standard_charges":[{"gross_charge":45432.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM PERM PM PULSE GEN W REPL PLSE GEN TWO LEAD SYS","code_information":[{"code":"7610000017","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33228","type":"HCPCS"}],"standard_charges":[{"gross_charge":45432.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INS IMPLTBL DFB GEN ONLY W EXISITING MULT LEADS","code_information":[{"code":"7610000019","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33231","type":"HCPCS"}],"standard_charges":[{"gross_charge":114225.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM TRANSVNS PM ELTRD ONE LEAD SYS ATR VENTR","code_information":[{"code":"7610000021","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33234","type":"HCPCS"}],"standard_charges":[{"gross_charge":12966.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INS OR REPM PERM IMPLTBL DFB W TRVEN LEAD SGL OR DUAL CHAM","code_information":[{"code":"7610000025","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33249","type":"HCPCS"}],"standard_charges":[{"gross_charge":96185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RMVL AND RPLCMT IMPLTBL DFB GEN SGL LEAD SYS","code_information":[{"code":"7610000026","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33262","type":"HCPCS"}],"standard_charges":[{"gross_charge":69696.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RMVL AND RPLCMT IMPLTBL DFB GEN DUAL LEAD SYS","code_information":[{"code":"7610000027","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33263","type":"HCPCS"}],"standard_charges":[{"gross_charge":69696.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO NEEDLE OR INTRACATH VEIN","code_information":[{"code":"7610000033","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36000","type":"HCPCS"}],"standard_charges":[{"gross_charge":425.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC LOCAL TRTMT EXTR PSEUDOANEURYSM","code_information":[{"code":"7610000034","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36002","type":"HCPCS"}],"standard_charges":[{"gross_charge":1178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ PROC FOR EXT VENGRAPHY INCL INTRO NEEDLE INTRACATH","code_information":[{"code":"7610000035","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36005","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO CATH SUPERIOR INFERIOR VENA CAVA","code_information":[{"code":"7610000036","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36010","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE VENOUS SYS 1ST ORD BRANCH","code_information":[{"code":"7610000037","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36011","type":"HCPCS"}],"standard_charges":[{"gross_charge":8930.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE VENOUS SYS 2ND ORD BRANCH","code_information":[{"code":"7610000038","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36012","type":"HCPCS"}],"standard_charges":[{"gross_charge":434.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE LT RT PULMONARY ARTERY","code_information":[{"code":"7610000040","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36014","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO NEEDLE INTRACATH EXTREMITY ARTERY","code_information":[{"code":"7610000043","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36140","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRO CATH AORTA","code_information":[{"code":"7610000045","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36200","type":"HCPCS"}],"standard_charges":[{"gross_charge":468.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS EA 1ST ORD","code_information":[{"code":"7610000046","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36215","type":"HCPCS"}],"standard_charges":[{"gross_charge":6869.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS INIT 3RD ORD","code_information":[{"code":"7610000048","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36217","type":"HCPCS"}],"standard_charges":[{"gross_charge":6869.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS ADD 2ND ORD","code_information":[{"code":"7610000049","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36218","type":"HCPCS"}],"standard_charges":[{"gross_charge":1165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE W ANGIOGRAPHY EXTRACRANIAL CAROTID","code_information":[{"code":"7610000050","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36223","type":"HCPCS"}],"standard_charges":[{"gross_charge":8156.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE INTERNAL CAROTID ARTERY","code_information":[{"code":"7610000051","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36224","type":"HCPCS"}],"standard_charges":[{"gross_charge":9903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE SUBCLAVIAN INNOMINATE ARTERY","code_information":[{"code":"7610000052","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36225","type":"HCPCS"}],"standard_charges":[{"gross_charge":8280.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE VETEBRAL ARTERY","code_information":[{"code":"7610000053","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36226","type":"HCPCS"}],"standard_charges":[{"gross_charge":9903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE EXTERNAL CAROTID ARTERY","code_information":[{"code":"7610000054","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36227","type":"HCPCS"}],"standard_charges":[{"gross_charge":6869.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS EA 1ST ORD","code_information":[{"code":"7610000056","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36245","type":"HCPCS"}],"standard_charges":[{"gross_charge":565.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS INIT 2ND ORD","code_information":[{"code":"7610000057","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36246","type":"HCPCS"}],"standard_charges":[{"gross_charge":476.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS INIT 3RD ORD","code_information":[{"code":"7610000058","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36247","type":"HCPCS"}],"standard_charges":[{"gross_charge":3618.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE ARTERIAL SYS ADD 2ND ORD","code_information":[{"code":"7610000059","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36248","type":"HCPCS"}],"standard_charges":[{"gross_charge":1165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SELECT CATH PLACE 1ST ORD UNILAT","code_information":[{"code":"7610000060","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36251","type":"HCPCS"}],"standard_charges":[{"gross_charge":8929.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUPERSELECT CATH PLACE RENAL ARTERY UNILAT","code_information":[{"code":"7610000062","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36253","type":"HCPCS"}],"standard_charges":[{"gross_charge":6409.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENIPUNCTURE 3 YRS OR OLDER PHYSICIAN SKILL","code_information":[{"code":"7610000063","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36410","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOVENOUS ABLATION THER INCOMPETENT VEIN 1ST VEIN","code_information":[{"code":"7610000064","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36478","type":"HCPCS"}],"standard_charges":[{"gross_charge":6932.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VENOUS CATH SELECTIVE ORGAN BLOOD SAMPLING","code_information":[{"code":"7610000066","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36500","type":"HCPCS"}],"standard_charges":[{"gross_charge":367.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT TUNNELED CVC WO SUBC PORT PMP OVER 5 YEARS OLD","code_information":[{"code":"7610000072","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36558","type":"HCPCS"}],"standard_charges":[{"gross_charge":3469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT TUNNELED CTR VAD W SUBC PORT OVER 5 YEARS OLD","code_information":[{"code":"7610000073","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36561","type":"HCPCS"}],"standard_charges":[{"gross_charge":4380.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE COMPL NON TUN CVC WO SUBC PORTOR PUMP","code_information":[{"code":"7610000074","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36580","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE COMPL TUN CVC WO SUBC POR OR PUMP","code_information":[{"code":"7610000075","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36581","type":"HCPCS"}],"standard_charges":[{"gross_charge":4469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE COMPL TUN CTR VAD W SUBC PORT","code_information":[{"code":"7610000076","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36582","type":"HCPCS"}],"standard_charges":[{"gross_charge":4394.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ARTERIAL CATH CANNUL MNTR TRANSFUSION SEP PROC LOCAL","code_information":[{"code":"7610000077","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36620","type":"HCPCS"}],"standard_charges":[{"gross_charge":1515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT","code_information":[{"code":"7610000079","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37182","type":"HCPCS"}],"standard_charges":[{"gross_charge":5585.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVISE TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT","code_information":[{"code":"7610000080","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37183","type":"HCPCS"}],"standard_charges":[{"gross_charge":22337.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRIM LOCAL TRANSLUMINAL MCHNL THRMBC 1ST VESSEL","code_information":[{"code":"7610000081","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37184","type":"HCPCS"}],"standard_charges":[{"gross_charge":10718.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRIM LOCAL TRANSLUMINAL MCHNL THRMBC SUBSQ VESSEL","code_information":[{"code":"7610000082","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37185","type":"HCPCS"}],"standard_charges":[{"gross_charge":6728.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUMINAL MCHNL THRMBC VEIN","code_information":[{"code":"7610000083","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37187","type":"HCPCS"}],"standard_charges":[{"gross_charge":8731.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSLUMINAL MCHNL THRMBC VEIN REPEAT TRTMT","code_information":[{"code":"7610000084","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37188","type":"HCPCS"}],"standard_charges":[{"gross_charge":8596.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT INTRVAS VC FILTR W WO VAS ACS VSL SELXN","code_information":[{"code":"7610000085","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37191","type":"HCPCS"}],"standard_charges":[{"gross_charge":9534.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RETRIEVE INTRVAS VC FILTR W WO ACS VSL SELXN","code_information":[{"code":"7610000086","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37193","type":"HCPCS"}],"standard_charges":[{"gross_charge":7559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THROMBOLYSIS CEREBRAL IV INFUSION","code_information":[{"code":"7610000087","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37195","type":"HCPCS"}],"standard_charges":[{"gross_charge":2225.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC TRANSCATH RTRVL INTRVAS FB W IMAGE","code_information":[{"code":"7610000088","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37197","type":"HCPCS"}],"standard_charges":[{"gross_charge":4960.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH BIOPSY","code_information":[{"code":"7610000089","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37200","type":"HCPCS"}],"standard_charges":[{"gross_charge":7274.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH THER THROMBOLYSIS ARTERIAL INFUS W IMAGE INIT","code_information":[{"code":"7610000091","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37211","type":"HCPCS"}],"standard_charges":[{"gross_charge":8291.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCATH THER THROMBOLYSIS VENOUS INFUS W IMAGE INIT","code_information":[{"code":"7610000092","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37212","type":"HCPCS"}],"standard_charges":[{"gross_charge":3271.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CESSATION OR THROMBOLYTIC THER W CATH REMOVAL","code_information":[{"code":"7610000093","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37214","type":"HCPCS"}],"standard_charges":[{"gross_charge":1880.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION ILIAC ARTERY ANGIOPLASTY 1ST VESSEL","code_information":[{"code":"7610000095","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37220","type":"HCPCS"}],"standard_charges":[{"gross_charge":17160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION ILIAC ARTERY STENT PLACE 1ST VESSEL","code_information":[{"code":"7610000096","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37221","type":"HCPCS"}],"standard_charges":[{"gross_charge":24989.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION ILIAC ARTERY ANGIOPLASTY EA ADD VESSEL","code_information":[{"code":"7610000097","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37222","type":"HCPCS"}],"standard_charges":[{"gross_charge":11544.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION ILIAC ARTERY STENT PLACE EA ADD VESSEL","code_information":[{"code":"7610000098","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37223","type":"HCPCS"}],"standard_charges":[{"gross_charge":11544.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION FEMORAL ARTERY ANGIOPLASTY","code_information":[{"code":"7610000099","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37224","type":"HCPCS"}],"standard_charges":[{"gross_charge":11544.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION FEMORAL ARTERY ATHERECTOMY","code_information":[{"code":"7610000100","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37225","type":"HCPCS"}],"standard_charges":[{"gross_charge":17626.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION FEMORAL ARTERY STENT PLACE ANGIOPLASTY","code_information":[{"code":"7610000101","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37226","type":"HCPCS"}],"standard_charges":[{"gross_charge":23788.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION FEMORAL ARTERY STENT PLACE ATHERECTOMY","code_information":[{"code":"7610000102","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37227","type":"HCPCS"}],"standard_charges":[{"gross_charge":42962.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION TIBIAL ARTERY ANGIOPLASTY","code_information":[{"code":"7610000103","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37228","type":"HCPCS"}],"standard_charges":[{"gross_charge":24989.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZATION TIBIAL ARTERY ATHERECTOMY","code_information":[{"code":"7610000104","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37232","type":"HCPCS"}],"standard_charges":[{"gross_charge":13859.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPEN PERC PLACE INTRAVASC STENT INIT","code_information":[{"code":"7610000105","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37236","type":"HCPCS"}],"standard_charges":[{"gross_charge":23788.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPEN PERC PLACE INTRAVASC STENT EA ADD","code_information":[{"code":"7610000106","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37237","type":"HCPCS"}],"standard_charges":[{"gross_charge":618.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPEN PERC PLACEMENT INTRAVASCULAR STENT SAME 1ST","code_information":[{"code":"7610000107","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37238","type":"HCPCS"}],"standard_charges":[{"gross_charge":23866.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPEN PERC PLACEMENT INTRAVASC STENT SAME EA ADD","code_information":[{"code":"7610000108","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37239","type":"HCPCS"}],"standard_charges":[{"gross_charge":11087.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS","code_information":[{"code":"7610000109","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37241","type":"HCPCS"}],"standard_charges":[{"gross_charge":22435.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VASCULAR EMBOLIZATION OR OCCLUSION ARTERIAL","code_information":[{"code":"7610000110","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37242","type":"HCPCS"}],"standard_charges":[{"gross_charge":20839.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VASCULAR EMBOLIZE OCCLUDE ORGAN TUMOR INFARCT","code_information":[{"code":"7610000111","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37243","type":"HCPCS"}],"standard_charges":[{"gross_charge":23802.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VASCULAR EMBOLIZATION OR OCCLUSION HEMORRHAGE","code_information":[{"code":"7610000112","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37244","type":"HCPCS"}],"standard_charges":[{"gross_charge":23802.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RENAL BIOPSY PERC TROCAR NEEDLE","code_information":[{"code":"7610000116","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50200","type":"HCPCS"}],"standard_charges":[{"gross_charge":1488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMAND REPLACE INTLY DWELLING URETERAL STENT PERC","code_information":[{"code":"7610000117","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50382","type":"HCPCS"}],"standard_charges":[{"gross_charge":5621.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM INTERN DWELLING URETERAL STENT PERC","code_information":[{"code":"7610000118","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50384","type":"HCPCS"}],"standard_charges":[{"gross_charge":8229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM AND REPLACE EXT ACCESSIBLE URETERAL STENT","code_information":[{"code":"7610000119","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50387","type":"HCPCS"}],"standard_charges":[{"gross_charge":3351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REM NEPHROSTOMY TUBE REQ FLUOR GUIDANCE","code_information":[{"code":"7610000120","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50389","type":"HCPCS"}],"standard_charges":[{"gross_charge":4107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASPIRATION AND OR INJ RENAL CYST PELVIS NEEDLE PERC","code_information":[{"code":"7610000121","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50390","type":"HCPCS"}],"standard_charges":[{"gross_charge":1488.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MANOMETRIC STDS THROUGH TUBE NDWELLG URTRL CATH","code_information":[{"code":"7610000126","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50396","type":"HCPCS"}],"standard_charges":[{"gross_charge":7246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RENAL NDSC NEPHROS PYELOSTOMY REMOVAL FB CALCULUS","code_information":[{"code":"7610000128","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50561","type":"HCPCS"}],"standard_charges":[{"gross_charge":6665.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABLATION RENAL TUMOR UNILAT PERC CRYOTHERAPY","code_information":[{"code":"7610000129","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50593","type":"HCPCS"}],"standard_charges":[{"gross_charge":10054.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ VISUALIZATION ILEAL CONDUIT AND OR URETEROPYELOG","code_information":[{"code":"7610000131","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50690","type":"HCPCS"}],"standard_charges":[{"gross_charge":1165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASPIRATION BLADDER INS SUPRAPUBIC CATH","code_information":[{"code":"7610000135","type":"CDM"},{"code":"0761","type":"RC"},{"code":"51102","type":"HCPCS"}],"standard_charges":[{"gross_charge":3535.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COMBI CATH PROC NON BRONCHOSCOPIC ALVEOLAR LAVAGE","code_information":[{"code":"7610000137","type":"CDM"},{"code":"0761","type":"RC"},{"code":"32999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1105.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT PULSE GENER DUAL CHMBR","code_information":[{"code":"7610000146","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33213","type":"HCPCS"}],"standard_charges":[{"gross_charge":32495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INS IMPLTBL DFB GEN ONLY W EXISITING DUAL LEADS","code_information":[{"code":"7610000148","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33230","type":"HCPCS"}],"standard_charges":[{"gross_charge":69696.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOVENOUS LASER VEIN ADDON","code_information":[{"code":"7610000160","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36479","type":"HCPCS"}],"standard_charges":[{"gross_charge":4140.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT TUNNELED CV CATH W 2 ACCESS SITES, W/ PUMP OR PORT","code_information":[{"code":"7610000161","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36566","type":"HCPCS"}],"standard_charges":[{"gross_charge":16785.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT PICC W/O SUB-Q PORT <5 Y/O","code_information":[{"code":"7610000162","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36568","type":"HCPCS"}],"standard_charges":[{"gross_charge":4743.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT PICC W/ SUB-Q PORT","code_information":[{"code":"7610000163","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36571","type":"HCPCS"}],"standard_charges":[{"gross_charge":3844.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE CV CATH, CATHETER ONLY W SUBQ PUMP OR PORT","code_information":[{"code":"7610000164","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36578","type":"HCPCS"}],"standard_charges":[{"gross_charge":5790.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPLACE PICC W PORT OR PUMP","code_information":[{"code":"7610000165","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36585","type":"HCPCS"}],"standard_charges":[{"gross_charge":5264.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANASTOMOSIS,AV,ANY SITE","code_information":[{"code":"7610000167","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36821","type":"HCPCS"}],"standard_charges":[{"gross_charge":11214.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REPSNG INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I","code_information":[{"code":"7610000169","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37192","type":"HCPCS"}],"standard_charges":[{"gross_charge":7559.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZE TIBIAL/PERON ARTERY,ANGIOPLASTY/ATHERECTOMY INITIAL","code_information":[{"code":"7610000170","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37229","type":"HCPCS"}],"standard_charges":[{"gross_charge":41576.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASCULARIZE TIBIAL/PERON ARTERY,ANGIOPLASTY/STENT/ATHERECTOMY INIT","code_information":[{"code":"7610000172","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37231","type":"HCPCS"}],"standard_charges":[{"gross_charge":34091.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECTION FOR SALIVARY X-RAY","code_information":[{"code":"7610000182","type":"CDM"},{"code":"0761","type":"RC"},{"code":"42550","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERC RADIOFREQ ABLATE RENAL TUMOR","code_information":[{"code":"7610000196","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50592","type":"HCPCS"}],"standard_charges":[{"gross_charge":9713.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHANGE OF URETEROSTOMY TUBE VIA ILEAL CONDUIT","code_information":[{"code":"7610000197","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50688","type":"HCPCS"}],"standard_charges":[{"gross_charge":3145.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTOSCOPY,GUIDE,PERCUT NEPHROS","code_information":[{"code":"7610000201","type":"CDM"},{"code":"0761","type":"RC"},{"code":"52334","type":"HCPCS"}],"standard_charges":[{"gross_charge":7852.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ENDOCRINE SURGERY PROC UNLISTED","code_information":[{"code":"7610000205","type":"CDM"},{"code":"0761","type":"RC"},{"code":"60699","type":"HCPCS"}],"standard_charges":[{"gross_charge":9840.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ,NEUROLYTIC,SUBARACHNOID","code_information":[{"code":"7610000210","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62280","type":"HCPCS"}],"standard_charges":[{"gross_charge":8579.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT NEUROLYTIC,EPIDUR,CERV/THOR","code_information":[{"code":"7610000211","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62281","type":"HCPCS"}],"standard_charges":[{"gross_charge":3351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ,NEUROLYTIC,EPID/LUMB/CAUDAL","code_information":[{"code":"7610000212","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62282","type":"HCPCS"}],"standard_charges":[{"gross_charge":3968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ,CERV/THORAC,FOR DISKOGRAPHY","code_information":[{"code":"7610000213","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62291","type":"HCPCS"}],"standard_charges":[{"gross_charge":6869.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE SPINAL CANAL CATHETER","code_information":[{"code":"7610000214","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62355","type":"HCPCS"}],"standard_charges":[{"gross_charge":4762.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT/ PREPLACE INFUSN PUMP,NONPROGRAM","code_information":[{"code":"7610000215","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62361","type":"HCPCS"}],"standard_charges":[{"gross_charge":33505.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT/ REPLACE INFUSN PUMP,PROGRAMMABLE","code_information":[{"code":"7610000216","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62362","type":"HCPCS"}],"standard_charges":[{"gross_charge":33505.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE INFUSN DEVICE/PUMP","code_information":[{"code":"7610000217","type":"CDM"},{"code":"0761","type":"RC"},{"code":"62365","type":"HCPCS"}],"standard_charges":[{"gross_charge":7274.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE SPINAL NEUROSTIM ELECTRODE PERC ARRAY, INCL FLUORO","code_information":[{"code":"7610000218","type":"CDM"},{"code":"0761","type":"RC"},{"code":"63661","type":"HCPCS"}],"standard_charges":[{"gross_charge":4895.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVE SPINAL NEUROSTIM ELECTRODE PLATE/PADDLE, INCL FLUORO","code_information":[{"code":"7610000219","type":"CDM"},{"code":"0761","type":"RC"},{"code":"63662","type":"HCPCS"}],"standard_charges":[{"gross_charge":4630.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVISION SPINAL NEUROSTIM ELECTRODE PERC ARRAY, INCL FLUORO","code_information":[{"code":"7610000220","type":"CDM"},{"code":"0761","type":"RC"},{"code":"63663","type":"HCPCS"}],"standard_charges":[{"gross_charge":13223.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVISION SPINAL NEUROSTIM ELECTRODE PLATE/PADDLE, INCL FLUORO","code_information":[{"code":"7610000221","type":"CDM"},{"code":"0761","type":"RC"},{"code":"63664","type":"HCPCS"}],"standard_charges":[{"gross_charge":10250.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT TRIGEM NERV,1ST BRANCH","code_information":[{"code":"7610000223","type":"CDM"},{"code":"0761","type":"RC"},{"code":"64600","type":"HCPCS"}],"standard_charges":[{"gross_charge":3351.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECTION TREATMENT OF NERVE","code_information":[{"code":"7610000224","type":"CDM"},{"code":"0761","type":"RC"},{"code":"64681","type":"HCPCS"}],"standard_charges":[{"gross_charge":3911.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ABLATION BONE TUM CRYO PERQ W IMG GUIDE WHEN PERF","code_information":[{"code":"7610000226","type":"CDM"},{"code":"0761","type":"RC"},{"code":"20983","type":"HCPCS"}],"standard_charges":[{"gross_charge":11242.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ VERTEBROPLASTY UNI OR BI INJ CERVICOTHOR","code_information":[{"code":"7610000227","type":"CDM"},{"code":"0761","type":"RC"},{"code":"22510","type":"HCPCS"}],"standard_charges":[{"gross_charge":4565.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ VERTEBROPLASTY UNI OR BI INJ LMBR","code_information":[{"code":"7610000228","type":"CDM"},{"code":"0761","type":"RC"},{"code":"22511","type":"HCPCS"}],"standard_charges":[{"gross_charge":6850.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VERTEBROPLASTY EA ADDL CERVICOTHOR OR LMBR","code_information":[{"code":"7610000229","type":"CDM"},{"code":"0761","type":"RC"},{"code":"22512","type":"HCPCS"}],"standard_charges":[{"gross_charge":1985.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ VERT AGMNT KYPHOPLASTY THOR UNI OR BI 1ST VERT","code_information":[{"code":"7610000230","type":"CDM"},{"code":"0761","type":"RC"},{"code":"22513","type":"HCPCS"}],"standard_charges":[{"gross_charge":38690.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ VERT AGMNT KYPHOPLASTY LMBR UNI OR BI 1ST VERT","code_information":[{"code":"7610000231","type":"CDM"},{"code":"0761","type":"RC"},{"code":"22514","type":"HCPCS"}],"standard_charges":[{"gross_charge":38690.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ VERT AGMNT KYPHOPLASTY UNI OR BI EA ADDL THOR OR LMBR","code_information":[{"code":"7610000232","type":"CDM"},{"code":"0761","type":"RC"},{"code":"22515","type":"HCPCS"}],"standard_charges":[{"gross_charge":6613.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERT PERIPHERAL CVC PICC WO SUBQ PORT OVER 5 YEARS","code_information":[{"code":"7610000233","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36569","type":"HCPCS"}],"standard_charges":[{"gross_charge":3469.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ SAC AGMNTJ UNI W/WO BALO/MCHNL DEV 1 > NDL","code_information":[{"code":"7610000235","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0200T","type":"HCPCS"}],"standard_charges":[{"gross_charge":6702.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SKIN SUB TAL 1ST 25SCM","code_information":[{"code":"7610000240","type":"CDM"},{"code":"0761","type":"RC"},{"code":"15271","type":"HCPCS"}],"standard_charges":[{"gross_charge":3134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL SKIN SUB TAL EA ADDL 25SCM","code_information":[{"code":"7610000241","type":"CDM"},{"code":"0761","type":"RC"},{"code":"15272","type":"HCPCS"}],"standard_charges":[{"gross_charge":438.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APP SKIN SUB TAL 1ST 100SCM","code_information":[{"code":"7610000242","type":"CDM"},{"code":"0761","type":"RC"},{"code":"15273","type":"HCPCS"}],"standard_charges":[{"gross_charge":5026.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APP SKIN SUB HGHFD 1ST 25SCM","code_information":[{"code":"7610000243","type":"CDM"},{"code":"0761","type":"RC"},{"code":"15275","type":"HCPCS"}],"standard_charges":[{"gross_charge":3029.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APP SKIN SUB HGHFD EA ADDL 25SCM","code_information":[{"code":"7610000244","type":"CDM"},{"code":"0761","type":"RC"},{"code":"15276","type":"HCPCS"}],"standard_charges":[{"gross_charge":273.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC ST TUMOR SHOULDER SUBC < 3CM","code_information":[{"code":"7610000246","type":"CDM"},{"code":"0761","type":"RC"},{"code":"23075","type":"HCPCS"}],"standard_charges":[{"gross_charge":3856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC GANGLION WRIST PRIMARY","code_information":[{"code":"7610000247","type":"CDM"},{"code":"0761","type":"RC"},{"code":"25111","type":"HCPCS"}],"standard_charges":[{"gross_charge":5531.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXC ST TUMOR PELVIS HIP SUBC > 3CM","code_information":[{"code":"7610000252","type":"CDM"},{"code":"0761","type":"RC"},{"code":"27043","type":"HCPCS"}],"standard_charges":[{"gross_charge":5753.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OSTECTOMY COMPLETE 5TH METATARSAL HEAD","code_information":[{"code":"7610000257","type":"CDM"},{"code":"0761","type":"RC"},{"code":"28113","type":"HCPCS"}],"standard_charges":[{"gross_charge":10075.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASC TIBIAL A EA ADDL W ATHERECTOMY","code_information":[{"code":"7610000271","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37233","type":"HCPCS"}],"standard_charges":[{"gross_charge":13455.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCERVICAL INTRO FALLOPIAN TUBE CATH","code_information":[{"code":"7610000276","type":"CDM"},{"code":"0761","type":"RC"},{"code":"58345","type":"HCPCS"}],"standard_charges":[{"gross_charge":2698.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AMNIOCENTESIS DIAGNOSTIC","code_information":[{"code":"7610000277","type":"CDM"},{"code":"0761","type":"RC"},{"code":"59000","type":"HCPCS"}],"standard_charges":[{"gross_charge":728.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SUTURE DIGITAL NERVE HAND FOOT","code_information":[{"code":"7610000280","type":"CDM"},{"code":"0761","type":"RC"},{"code":"64831","type":"HCPCS"}],"standard_charges":[{"gross_charge":11586.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEUROSTIM GENERATOR PROGRAMNG SIMPLE INTRAOP","code_information":[{"code":"7610000285","type":"CDM"},{"code":"0761","type":"RC"},{"code":"95971","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EXISTION ACCESS","code_information":[{"code":"7610000287","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50431","type":"HCPCS"}],"standard_charges":[{"gross_charge":3618.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACE NEPHROSTOMY CATH PERC INC DX NEPHROSTOGRAM AND/OR FLUOROSCOPY","code_information":[{"code":"7610000288","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50432","type":"HCPCS"}],"standard_charges":[{"gross_charge":4107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACE NEPHROURETERAL CATH PERC INC DX NEPHRO AND/OR URETEROGRAM PRFRMD IMAGE GUIDE NEW ACCESS","code_information":[{"code":"7610000289","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50433","type":"HCPCS"}],"standard_charges":[{"gross_charge":4358.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CONV NEPH TO NEPHROURET CATH PERC INC DX NEPH URETGRM PERF VIA PRE EXIST NEPH TRACT","code_information":[{"code":"7610000290","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50434","type":"HCPCS"}],"standard_charges":[{"gross_charge":1872.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CHANGE NEPH CATH INC DX NEPH OR UTEROGRAM INC GUIDE & INTERPRT","code_information":[{"code":"7610000291","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50435","type":"HCPCS"}],"standard_charges":[{"gross_charge":1581.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACE URETERAL STENT PERC INC DX NEPHROSTOGRAM AND/OR FLUOROSCOPY PREEXIST NEPHROSTOMY TRACT","code_information":[{"code":"7610000292","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50693","type":"HCPCS"}],"standard_charges":[{"gross_charge":5480.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEW ACCESS W/O SEPARATE NEPHROSTOMY CATH","code_information":[{"code":"7610000293","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50694","type":"HCPCS"}],"standard_charges":[{"gross_charge":5480.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEW ACCESS W SEPARATE NEPHROSTOMY CATH","code_information":[{"code":"7610000294","type":"CDM"},{"code":"0761","type":"RC"},{"code":"50695","type":"HCPCS"}],"standard_charges":[{"gross_charge":5480.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PLACE LOCAL DEV FIDUCL MRKR PERC OR INTRATHOR","code_information":[{"code":"7610000295","type":"CDM"},{"code":"0761","type":"RC"},{"code":"32999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1704.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTRAORAL ABCESS DRAIN SUBLINGUAL OR SUBMAX","code_information":[{"code":"7610000296","type":"CDM"},{"code":"0761","type":"RC"},{"code":"42310","type":"HCPCS"}],"standard_charges":[{"gross_charge":1009.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRLML BALO ANGIOP OPEN PERQ IMG SANDI 1ST ART","code_information":[{"code":"7610000304","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37246","type":"HCPCS"}],"standard_charges":[{"gross_charge":8566.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRLML BALO ANGIOP OPEN PERQ IMG SANDI EA ADDL ART","code_information":[{"code":"7610000305","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37247","type":"HCPCS"}],"standard_charges":[{"gross_charge":1035.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRLML BALO ANGIOP OPEN PERQ W IMG SANDI 1ST VEIN","code_information":[{"code":"7610000306","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37248","type":"HCPCS"}],"standard_charges":[{"gross_charge":11286.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRLML BALO ANGIOP OPEN PERQ W IMG SANDI ADDL VEIN","code_information":[{"code":"7610000307","type":"CDM"},{"code":"0761","type":"RC"},{"code":"37249","type":"HCPCS"}],"standard_charges":[{"gross_charge":2772.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC THROMBOENDARTECTMY FEMORAL DEEP","code_information":[{"code":"7610000312","type":"CDM"},{"code":"0761","type":"RC"},{"code":"35372","type":"HCPCS"}],"standard_charges":[{"gross_charge":16606.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPN AXILLARY/SUBCLAVIAN ART EXPOS W/CNDT CRTJ","code_information":[{"code":"7610000330","type":"CDM"},{"code":"0761","type":"RC"},{"code":"34716","type":"HCPCS"}],"standard_charges":[{"gross_charge":1056.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ ACCESS & CLOSURE FEM ART FOR DEL NDGFT","code_information":[{"code":"7610000335","type":"CDM"},{"code":"0761","type":"RC"},{"code":"34713","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERQ ART TRLUML M-THROMBEC & NFS INTRACRANIAL","code_information":[{"code":"7610000337","type":"CDM"},{"code":"0761","type":"RC"},{"code":"61645","type":"HCPCS"}],"standard_charges":[{"gross_charge":9495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERTION PICC W RS&I < 5 YR","code_information":[{"code":"7610000339","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36572","type":"HCPCS"}],"standard_charges":[{"gross_charge":1681.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERTION PICC W RS&I 5 YR/>","code_information":[{"code":"7610000340","type":"CDM"},{"code":"0761","type":"RC"},{"code":"36573","type":"HCPCS"}],"standard_charges":[{"gross_charge":2963.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERTION WRLS CAR STIMULATOR LV PACG COMPL SYS","code_information":[{"code":"7610000341","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0515T","type":"HCPCS"}],"standard_charges":[{"gross_charge":83783.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERTION WRLS CAR STIMULATOR LV PACG ELTRD ONLY","code_information":[{"code":"7610000342","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0516T","type":"HCPCS"}],"standard_charges":[{"gross_charge":27185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INSERTION WRLS CAR STIMULATOR LV PACG PG COMPNT","code_information":[{"code":"7610000343","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0517T","type":"HCPCS"}],"standard_charges":[{"gross_charge":27185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL PG COMPNT ONLY WRLS CAR STIMULATOR","code_information":[{"code":"7610000344","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0518T","type":"HCPCS"}],"standard_charges":[{"gross_charge":11496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL&RPLCMT WRLS CAR STIMULATOR PG COMPNT","code_information":[{"code":"7610000345","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0519T","type":"HCPCS"}],"standard_charges":[{"gross_charge":11496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL&RPLCMT WRLS CAR STIMULATOR W NEW ELTRD","code_information":[{"code":"7610000346","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0520T","type":"HCPCS"}],"standard_charges":[{"gross_charge":83783.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERROG DEV EVAL WRLS CAR STIMULATOR IN PERSON","code_information":[{"code":"7610000347","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0521T","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PRGRMG DEVICE EVAL WRLS CAR STIMULATOR IN PERSON","code_information":[{"code":"7610000348","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0522T","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLONOSCOPY VIA STOMA W/CHROMOENDOSCOPY","code_information":[{"code":"7610000353","type":"CDM"},{"code":"0761","type":"RC"},{"code":"45399","type":"HCPCS"}],"standard_charges":[{"gross_charge":2831.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PERICARDIOCENTESIS W IMG GUIDANCE WHEN PERFORMED","code_information":[{"code":"7610000354","type":"CDM"},{"code":"0761","type":"RC"},{"code":"33016","type":"HCPCS"}],"standard_charges":[{"gross_charge":5148.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IVL,REVASCULARIZE ILIAC ARTERY,ANGIOPLASTY, INITIAL VESSEL","code_information":[{"code":"7610000364","type":"CDM"},{"code":"0761","type":"RC"},{"code":"C9764","type":"HCPCS"}],"standard_charges":[{"gross_charge":11871.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IVL,REVASCULARIZE ILIAC ARTERY,ANGIOPLASTY/STENT, INITIAL VESSEL","code_information":[{"code":"7610000365","type":"CDM"},{"code":"0761","type":"RC"},{"code":"C9765","type":"HCPCS"}],"standard_charges":[{"gross_charge":53870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IRE ABLATION 1+TUMORS PER ORGAN W/IMG GDN PERQ","code_information":[{"code":"7610000369","type":"CDM"},{"code":"0761","type":"RC"},{"code":"0600T","type":"HCPCS"}],"standard_charges":[{"gross_charge":32327.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REVASC LITHOTRIP TIBI PERONE","code_information":[{"code":"7610000374","type":"CDM"},{"code":"0761","type":"RC"},{"code":"C9772","type":"HCPCS"}],"standard_charges":[{"gross_charge":40403.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO W/DILAT RX BALO CATH URTL STRIX/STEN MALE","code_information":[{"code":"7610000391","type":"CDM"},{"code":"0761","type":"RC"},{"code":"52284","type":"HCPCS"}],"standard_charges":[{"gross_charge":12662.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MATERNITY CARE PROCEDURE","code_information":[{"code":"7610000394","type":"CDM"},{"code":"0761","type":"RC"},{"code":"59899","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC N BLOCK INJ COMMON DIGIT","code_information":[{"code":"7610000395","type":"CDM"},{"code":"0761","type":"RC"},{"code":"64632","type":"HCPCS"}],"standard_charges":[{"gross_charge":917.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CYSTO LITHO VACUUM KIDNEY","code_information":[{"code":"7610000397","type":"CDM"},{"code":"0761","type":"RC"},{"code":"C9761","type":"HCPCS"}],"standard_charges":[{"gross_charge":27741.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC REMOVAL IMPLANT FROM FINGER/HAND","code_information":[{"code":"7610000399","type":"CDM"},{"code":"0761","type":"RC"},{"code":"26320","type":"HCPCS"}],"standard_charges":[{"gross_charge":5031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NPWT >THAN OR = 50 SQCM W/DEVI","code_information":[{"code":"7611000554","type":"CDM"},{"code":"0761","type":"RC"},{"code":"97608","type":"HCPCS"}],"standard_charges":[{"gross_charge":968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSERVATION EACH ADD HOUR","code_information":[{"code":"7620000000","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSERVATION MOD COMP PER HR","code_information":[{"code":"7620000001","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99222","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSERVATION HIGH COMP PER HR","code_information":[{"code":"7620000002","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99223","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSERVATION DIRECT ADMIT","code_information":[{"code":"7620000003","type":"CDM"},{"code":"0762","type":"RC"},{"code":"G0379","type":"HCPCS"}],"standard_charges":[{"gross_charge":2625.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB MRI CARVE OUT REV CODE 610-612","code_information":[{"code":"7620000005","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB STRESS EKG CARVE OUT REV CODE 482","code_information":[{"code":"7620000007","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB ECHO CARVE OUT REV CODE 483","code_information":[{"code":"7620000008","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB NUCLEAR CARVE OUT REV CODE 340-341","code_information":[{"code":"7620000009","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB PT AND OT CARVE OUT REV CODE 420 AND 430","code_information":[{"code":"7620000010","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB DIAGNOSTIC XRAY CARVE OUT REV CODE 320 AND 324","code_information":[{"code":"7620000011","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB CT CARVE OUT REV CODE 350-352","code_information":[{"code":"7620000012","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB EEG CARVE OUT REV CODE 740","code_information":[{"code":"7620000013","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB ULTRASOUND CARVE OUT REV CODE 402","code_information":[{"code":"7620000014","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB VASCULAR LAB CARVE OUT REV CODE 921","code_information":[{"code":"7620000015","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB INFUSION CARVE OUT REV CODE 260","code_information":[{"code":"7620000016","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB RESP PULM CARVE OUT REV CODE 410 AND 460","code_information":[{"code":"7620000017","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HB BLOOD ADMIN CARVE OUT REV CODE 391","code_information":[{"code":"7620000018","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OBSERVATION - INITIAL HOUR FEE","code_information":[{"code":"7620000051","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RESP SERVICES CARVE OUT REV CODE 410","code_information":[{"code":"7620000053","type":"CDM"},{"code":"0762","type":"RC"},{"code":"99221","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CERV VAG SCREEN PELVIS BREAST EXAM","code_information":[{"code":"7700000000","type":"CDM"},{"code":"0770","type":"RC"},{"code":"G0101","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CANCER SCREEN PROSTATE","code_information":[{"code":"7700000001","type":"CDM"},{"code":"0770","type":"RC"},{"code":"G0102","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANNUAL WELLNESS VISIT INIT","code_information":[{"code":"7700000003","type":"CDM"},{"code":"0770","type":"RC"},{"code":"G0438","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANNUAL WELLNESS VISIT SUBS","code_information":[{"code":"7700000004","type":"CDM"},{"code":"0770","type":"RC"},{"code":"G0439","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS","code_information":[{"code":"7700000007","type":"CDM"},{"code":"0770","type":"RC"},{"code":"99383","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADMIN VACCIN SINGLE","code_information":[{"code":"7710000000","type":"CDM"},{"code":"0771","type":"RC"},{"code":"90471","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADMIN VACCINE ADD","code_information":[{"code":"7710000001","type":"CDM"},{"code":"0771","type":"RC"},{"code":"90472","type":"HCPCS"}],"standard_charges":[{"gross_charge":75.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADMIN INFLUENZA VACCINE","code_information":[{"code":"7710000004","type":"CDM"},{"code":"0771","type":"RC"},{"code":"G0008","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADMIN PNEUMOCOCCAL VACCINE","code_information":[{"code":"7710000005","type":"CDM"},{"code":"0771","type":"RC"},{"code":"90471","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADMIN HEP B VACCINE","code_information":[{"code":"7710000006","type":"CDM"},{"code":"0771","type":"RC"},{"code":"90471","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, 1ST VACCINE/TOXOID","code_information":[{"code":"7710000007","type":"CDM"},{"code":"0771","type":"RC"},{"code":"90460","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 30MCG 1ST DOSE","code_information":[{"code":"7710000009","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0001A","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 30MCG 2ND DOSE","code_information":[{"code":"7710000010","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0002A","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 100MCG 1ST DOSE","code_information":[{"code":"7710000011","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0011A","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 100MCG 2ND DOSE","code_information":[{"code":"7710000012","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0012A","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC JANSSEN COVID VACCINE ADMIN .5ML","code_information":[{"code":"7710000013","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0031A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 30MCG 3RD DOSE","code_information":[{"code":"7710000014","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0003A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 100MCG 3RD DOSE","code_information":[{"code":"7710000015","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0013A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 30MCG BOOSTER","code_information":[{"code":"7710000019","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0004A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 50MCG BOOSTER","code_information":[{"code":"7710000020","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0064A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 0.5ML BOOSTER","code_information":[{"code":"7710000021","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0034A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SOTROVIMAB INFUSION","code_information":[{"code":"7710000028","type":"CDM"},{"code":"0771","type":"RC"},{"code":"M0247","type":"HCPCS"}],"standard_charges":[{"gross_charge":1474.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TIXAGEV AND CILGAV INFUSION","code_information":[{"code":"7710000031","type":"CDM"},{"code":"0771","type":"RC"},{"code":"M0220","type":"HCPCS"}],"standard_charges":[{"gross_charge":286.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID VACCINE ADMIN 30MCG TRS-SUCR 1ST DOSE","code_information":[{"code":"7710000032","type":"CDM"},{"code":"0771","type":"RC"},{"code":"0051A","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BEBTELOVIMAB INFUSION ADMIN","code_information":[{"code":"7710000038","type":"CDM"},{"code":"0771","type":"RC"},{"code":"M0222","type":"HCPCS"}],"standard_charges":[{"gross_charge":480.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COVID-19 VACCINE ADMINISTATION","code_information":[{"code":"7710000053","type":"CDM"},{"code":"0771","type":"RC"},{"code":"90480","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX","code_information":[{"code":"7710000055","type":"CDM"},{"code":"0771","type":"RC"},{"code":"96381","type":"HCPCS"}],"standard_charges":[{"gross_charge":71.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TELEHEALTH FACILITY FEE","code_information":[{"code":"7800000001","type":"CDM"},{"code":"0780","type":"RC"},{"code":"Q3014","type":"HCPCS"}],"standard_charges":[{"gross_charge":149.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BASIC METABOLIC PANEL CALCIUM IONIZED","code_information":[{"code":"80047","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80047","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BASIC METABOLIC PANEL CALCIUM TOTAL","code_information":[{"code":"80048","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80048","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GENERAL HEALTH PANEL","code_information":[{"code":"80050","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80050","type":"HCPCS"}],"standard_charges":[{"gross_charge":146.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ELECTROLYTE PANEL","code_information":[{"code":"80051","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80051","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPREHENSIVE METABOLIC PANEL","code_information":[{"code":"80053","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80053","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OBSTETRIC PANEL","code_information":[{"code":"80055","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80055","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPID PANEL","code_information":[{"code":"80061","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80061","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG RENAL FUNCTION PANEL","code_information":[{"code":"80069","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80069","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACUTE HEPATITIS PANEL","code_information":[{"code":"80074","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80074","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATIC FUNCTION PANEL","code_information":[{"code":"80076","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80076","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OBSTETRIC PANEL INCLUDES HIV TESTING","code_information":[{"code":"80081","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80081","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEMODIALYSIS PROC W SINGLE EVAL","code_information":[{"code":"8010000000","type":"CDM"},{"code":"0821","type":"RC"},{"code":"90935","type":"HCPCS"}],"standard_charges":[{"gross_charge":2976.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY ACETAMINOPHEN","code_information":[{"code":"80143","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80143","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY ADALIMUMAB","code_information":[{"code":"80145","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80145","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE AMIKACIN","code_information":[{"code":"80150","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80150","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY AMIODARONE","code_information":[{"code":"80151","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80151","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY CAFFEINE","code_information":[{"code":"80155","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80155","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY CARBAMAZEPINE TOTAL","code_information":[{"code":"80156","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80156","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY CARBAMAZEPINE FREE","code_information":[{"code":"80157","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80157","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY CYCLOSPORINE","code_information":[{"code":"80158","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80158","type":"HCPCS"}],"standard_charges":[{"gross_charge":527.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY CLOZAPINE","code_information":[{"code":"80159","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80159","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE DIGOXIN TOTAL","code_information":[{"code":"80162","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80162","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY VALPROIC DIPROPYLACETIC ACID TOTAL","code_information":[{"code":"80164","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80164","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANT DIPROPYLACETIC ACID FREE","code_information":[{"code":"80165","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80165","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY FELBAMATE","code_information":[{"code":"80167","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80167","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE ETHOSUXIMIDE","code_information":[{"code":"80168","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80168","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY EVEROLIMUS","code_information":[{"code":"80169","type":"CDM"},{"code":"0300","type":"RC"},{"code":"80169","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE GENTAMICIN","code_information":[{"code":"80170","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80170","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE GABAPENTIN","code_information":[{"code":"80171","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80171","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE HALOPRIDOL","code_information":[{"code":"80173","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80173","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE LAMOTRIGINE","code_information":[{"code":"80175","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80175","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE LIDOCAINE","code_information":[{"code":"80176","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80176","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE LEVETIRACETAM","code_information":[{"code":"80177","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80177","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE LITHIUM","code_information":[{"code":"80178","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80178","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY SALICYLATE","code_information":[{"code":"80179","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80179","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE MYCOPHENOLATE","code_information":[{"code":"80180","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80180","type":"HCPCS"}],"standard_charges":[{"gross_charge":619.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY FLECAINIDE","code_information":[{"code":"80181","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80181","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE OXCARBAZEPINE","code_information":[{"code":"80183","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80183","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE PHENOBARBITAL","code_information":[{"code":"80184","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80184","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE PHENYTOIN TOTAL","code_information":[{"code":"80185","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80185","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE PHENYTOIN FREE","code_information":[{"code":"80186","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80186","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY POSACONAZOLE","code_information":[{"code":"80187","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80187","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE PRIMIDONE","code_information":[{"code":"80188","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80188","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY ITRACONAZOLE","code_information":[{"code":"80189","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80189","type":"HCPCS"}],"standard_charges":[{"gross_charge":167.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE PROCAINAMIDE METABOLITE","code_information":[{"code":"80192","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80192","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY LEFLUNOMIDE","code_information":[{"code":"80193","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80193","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE QUINIDINE","code_information":[{"code":"80194","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80194","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE SIROLIMUS","code_information":[{"code":"80195","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80195","type":"HCPCS"}],"standard_charges":[{"gross_charge":670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE TACROLIMUS","code_information":[{"code":"80197","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80197","type":"HCPCS"}],"standard_charges":[{"gross_charge":435.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE THEOPHYLLINE","code_information":[{"code":"80198","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80198","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE TIAGABINE","code_information":[{"code":"80199","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80199","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIALYSIS OTHER THAN HEMODIALYSIS W SINGLE EVAL","code_information":[{"code":"8020000000","type":"CDM"},{"code":"0802","type":"RC"},{"code":"90945","type":"HCPCS"}],"standard_charges":[{"gross_charge":1809.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE TOBRAMYCIN","code_information":[{"code":"80200","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80200","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE TOPIRAMATE","code_information":[{"code":"80201","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80201","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE VANCOMYCIN","code_information":[{"code":"80202","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80202","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE ZONISAMIDE","code_information":[{"code":"80203","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80203","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY METHOTREXATE","code_information":[{"code":"80204","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80204","type":"HCPCS"}],"standard_charges":[{"gross_charge":167.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY RUFINAMIDE","code_information":[{"code":"80210","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80210","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY HYDROXYCHLOROQUINE","code_information":[{"code":"80220","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80220","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY INFLIXIMAB","code_information":[{"code":"80230","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80230","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY LACOSAMIDE","code_information":[{"code":"80235","type":"CDM"},{"code":"0300","type":"RC"},{"code":"80235","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY VEDOLIZUMAB","code_information":[{"code":"80280","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80280","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG ASSAY VORICONAZOLE","code_information":[{"code":"80285","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80285","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG QUANTITATION DRUG NOT ELSEWHERE SPECIFIED","code_information":[{"code":"80299","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE","code_information":[{"code":"80305","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80305","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG TST PRSMV READ INSTRMNT ASSTD DIR OPT OBS","code_information":[{"code":"80306","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80306","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE","code_information":[{"code":"80307","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":256.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANTITATIVE ALCOHOLS","code_information":[{"code":"80320","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80320","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANT ALCOHOLS BIOMARKERS 1 OR 2","code_information":[{"code":"80321","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80321","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALKALOIDS NOT OTHERWISE SPECIFIED","code_information":[{"code":"80323","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80323","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANT AMPHETAMINES 1 OR 2","code_information":[{"code":"80324","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80324","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANT AMPHETAMINES 3 OR 4","code_information":[{"code":"80325","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80325","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN QUANT AMPHETAMINES 5 OR MORE","code_information":[{"code":"80326","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80326","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2","code_information":[{"code":"80329","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80329","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREEN ANALGESICS NON-OPIOID 3-5","code_information":[{"code":"80330","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80330","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIDEPRESSANTS SEROTONERGIC CLASS 1 OR 2","code_information":[{"code":"80332","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80332","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIDEPRESSANTS SEROTONERGIC CLASS 3-5","code_information":[{"code":"80333","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80333","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2","code_information":[{"code":"80335","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80335","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 6/MORE","code_information":[{"code":"80337","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80337","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIDEPRESSANTS NOT OTHERWISE SPECIFIED","code_information":[{"code":"80338","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80338","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3","code_information":[{"code":"80339","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80339","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 4-6","code_information":[{"code":"80340","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80340","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIPSYCHOTICS NOT OTHERWISE SPECIFIED 1-3","code_information":[{"code":"80342","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80342","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIPSYCHOTICS NOT OTHERWISE SPECIFIED 7/MORE","code_information":[{"code":"80344","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80344","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING BARBITURATES","code_information":[{"code":"80345","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80345","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING BENZODIAZEPINES 1-12","code_information":[{"code":"80346","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING BENZODIAZEPINES 13 OR MORE","code_information":[{"code":"80347","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80347","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING BUPRENORPHINE","code_information":[{"code":"80348","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80348","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING CANNABINOIDS NATURAL","code_information":[{"code":"80349","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80349","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING COCAINE","code_information":[{"code":"80353","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80353","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING FENTANYL","code_information":[{"code":"80354","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80354","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING GABAPENTIN NON-BLOOD","code_information":[{"code":"80355","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80355","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING HEROIN METABOLITE","code_information":[{"code":"80356","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80356","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING KETAMINE AND NORKETAMINE","code_information":[{"code":"80357","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80357","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING METHADONE","code_information":[{"code":"80358","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80358","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING METHYLENEDIOXYAMPHETAMINES","code_information":[{"code":"80359","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80359","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING METHYLPHENIDATE","code_information":[{"code":"80360","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80360","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING OPIATES 1 OR MORE","code_information":[{"code":"80361","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80361","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2","code_information":[{"code":"80362","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80362","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING OPIOIDS & OPIATE ANALOGS 5/MORE","code_information":[{"code":"80364","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80364","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING OXYCODONE","code_information":[{"code":"80365","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80365","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING PREGABALIN","code_information":[{"code":"80366","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80366","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING PROPOXYPHENE","code_information":[{"code":"80367","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80367","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING SEDATIVE HYPNOTICS","code_information":[{"code":"80368","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80368","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING SKELETAL MUSCLE RELAXANTS 1 OR 2","code_information":[{"code":"80369","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80369","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING SKEL MUSCLE RELAXANTS 3 OR MORE","code_information":[{"code":"80370","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80370","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING TAPENTADOL","code_information":[{"code":"80372","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80372","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG SCREENING TRAMADOL","code_information":[{"code":"80373","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80373","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 1-3","code_information":[{"code":"80375","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80375","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 7/MORE","code_information":[{"code":"80377","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80377","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACTH STIMULATION PANEL ADRENAL INSUFFICIENCY","code_information":[{"code":"80400","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80400","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE TOLERANCE PANEL INSULINOMA","code_information":[{"code":"80422","type":"CDM"},{"code":"0301","type":"RC"},{"code":"80422","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY","code_information":[{"code":"81000","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81000","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY","code_information":[{"code":"81001","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81001","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP","code_information":[{"code":"81002","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81002","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY","code_information":[{"code":"81003","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81003","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URINALYSIS QUAL/SEMIQUANT EXCEPT IMMUNOASSAYS","code_information":[{"code":"81005","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81005","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URINALYSIS MICROSCOPIC ONLY","code_information":[{"code":"81015","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81015","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS","code_information":[{"code":"81025","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81025","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VOLUME MEASUREMENT TIMED COLLECTION EACH","code_information":[{"code":"81050","type":"CDM"},{"code":"0301","type":"RC"},{"code":"81050","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UNLISTED URINALYSIS PROCEDURE","code_information":[{"code":"81099","type":"CDM"},{"code":"0307","type":"RC"},{"code":"81099","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-1 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81105","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81105","type":"HCPCS"}],"standard_charges":[{"gross_charge":571.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-2 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81106","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81106","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-3 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81107","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81107","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-4 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81108","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81108","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-5 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81109","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81109","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-6 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81110","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81110","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPA-15 GENOTYPING GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81112","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81112","type":"HCPCS"}],"standard_charges":[{"gross_charge":609.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IDH1 COMMON VARIANTS","code_information":[{"code":"81120","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81120","type":"HCPCS"}],"standard_charges":[{"gross_charge":600.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IDH2 COMMON VARIANTS","code_information":[{"code":"81121","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81121","type":"HCPCS"}],"standard_charges":[{"gross_charge":918.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DMD DUPLICATION/DELETION ANALYSIS","code_information":[{"code":"81161","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81161","type":"HCPCS"}],"standard_charges":[{"gross_charge":866.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRCA1 BRCA2 GENE ALYS FULL SEQ FULL DUP/DEL ALYS","code_information":[{"code":"81162","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81162","type":"HCPCS"}],"standard_charges":[{"gross_charge":6450.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS","code_information":[{"code":"81163","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81163","type":"HCPCS"}],"standard_charges":[{"gross_charge":1418.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRCA1 BRCA2 GENE ANALYSIS FULL DUP/DEL ANALYSIS","code_information":[{"code":"81164","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81164","type":"HCPCS"}],"standard_charges":[{"gross_charge":1773.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRCA1 GENE ANALYSIS FULL SEQUENCE ANALYSIS","code_information":[{"code":"81165","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81165","type":"HCPCS"}],"standard_charges":[{"gross_charge":860.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRCA1 GENE ANALYSIS FULL DUP/DEL ANALYSIS","code_information":[{"code":"81166","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81166","type":"HCPCS"}],"standard_charges":[{"gross_charge":915.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRCA2 GENE ANALYSIS FULL DUP/DEL ANALYSIS","code_information":[{"code":"81167","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81167","type":"HCPCS"}],"standard_charges":[{"gross_charge":860.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ABL1 GENE ANALYSIS KINASE DOMAIN VARIANTS","code_information":[{"code":"81170","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81170","type":"HCPCS"}],"standard_charges":[{"gross_charge":1195.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AFF2 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81171","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81171","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AFF2 GENE ANALYSIS CHARACTERIZATION OF ALLELES","code_information":[{"code":"81172","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81172","type":"HCPCS"}],"standard_charges":[{"gross_charge":892.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AR GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81173","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81173","type":"HCPCS"}],"standard_charges":[{"gross_charge":915.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AR GENE ANALYSIS KNOWN FAMILIAL VARIANT","code_information":[{"code":"81174","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81174","type":"HCPCS"}],"standard_charges":[{"gross_charge":601.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATN1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81177","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81177","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATXN1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81178","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81178","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATXN2 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81179","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81179","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATXN3 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81180","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81180","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATXN7 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81181","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81181","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATXN8OS GENE ANALYSIS EVAL DETECT ABNOR ALLELES","code_information":[{"code":"81182","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81182","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ATXN10 GENE ANALYSIS EVAL DETC ABNORMAL ALLELES","code_information":[{"code":"81183","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81183","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CACNA1A GENE ANALYSIS EVAL DETECT ABNOR ALLELES","code_information":[{"code":"81184","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81184","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CACNA1A GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81185","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81185","type":"HCPCS"}],"standard_charges":[{"gross_charge":2733.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CACNA1A GENE ANALYSIS KNOWN FAMILIAL VARIANT","code_information":[{"code":"81186","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81186","type":"HCPCS"}],"standard_charges":[{"gross_charge":564.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CNBP GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81187","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81187","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CSTB GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81188","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81188","type":"HCPCS"}],"standard_charges":[{"gross_charge":416.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CSTB GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81189","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81189","type":"HCPCS"}],"standard_charges":[{"gross_charge":892.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CSTB GENE ANALYSIS KNOWN FAMILIAL VARIANTS","code_information":[{"code":"81190","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81190","type":"HCPCS"}],"standard_charges":[{"gross_charge":564.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTOG GEN-WIDE ALYS HEM MAL STRUX VRNT&CNV OGM","code_information":[{"code":"81195","type":"CDM"},{"code":"0309","type":"RC"},{"code":"81195","type":"HCPCS"}],"standard_charges":[{"gross_charge":3924.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASPA GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81200","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81200","type":"HCPCS"}],"standard_charges":[{"gross_charge":305.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AR GENE ANALYSIS CHARACTERIZATION OF ALLELES","code_information":[{"code":"81204","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81204","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BCKDHB GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81205","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81205","type":"HCPCS"}],"standard_charges":[{"gross_charge":265.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE","code_information":[{"code":"81206","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81206","type":"HCPCS"}],"standard_charges":[{"gross_charge":817.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE","code_information":[{"code":"81207","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81207","type":"HCPCS"}],"standard_charges":[{"gross_charge":720.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BCR/ABL1 OTHER BREAKPNT QUALITATIVE/QUANTITATIVE","code_information":[{"code":"81208","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81208","type":"HCPCS"}],"standard_charges":[{"gross_charge":667.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLM GENE ANALYSIS 2281DEL6INS7 VARIANT","code_information":[{"code":"81209","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81209","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BRAF GENE ANALYSIS V600 VARIANT(S)","code_information":[{"code":"81210","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81210","type":"HCPCS"}],"standard_charges":[{"gross_charge":552.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CEBPA GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81218","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81218","type":"HCPCS"}],"standard_charges":[{"gross_charge":758.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9","code_information":[{"code":"81219","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81219","type":"HCPCS"}],"standard_charges":[{"gross_charge":602.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CFTR GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81220","type":"CDM"},{"code":"0301","type":"RC"},{"code":"81220","type":"HCPCS"}],"standard_charges":[{"gross_charge":1115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS","code_information":[{"code":"81222","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81222","type":"HCPCS"}],"standard_charges":[{"gross_charge":1462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CFTR GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81223","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81223","type":"HCPCS"}],"standard_charges":[{"gross_charge":1720.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYP2C19 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81225","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81225","type":"HCPCS"}],"standard_charges":[{"gross_charge":1067.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYP2D6 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81226","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81226","type":"HCPCS"}],"standard_charges":[{"gross_charge":1639.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYP2C9 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81227","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81227","type":"HCPCS"}],"standard_charges":[{"gross_charge":663.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTOG ALYS CHRMOML ABNOR CPY NUMBER&SNP VRNT CGH","code_information":[{"code":"81229","type":"CDM"},{"code":"0301","type":"RC"},{"code":"81229","type":"HCPCS"}],"standard_charges":[{"gross_charge":3025.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYP3A4 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81230","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81230","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYP3A5 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81231","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81231","type":"HCPCS"}],"standard_charges":[{"gross_charge":663.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DPYD GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81232","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81232","type":"HCPCS"}],"standard_charges":[{"gross_charge":666.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BTK GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81233","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81233","type":"HCPCS"}],"standard_charges":[{"gross_charge":534.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DMPK GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81234","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81234","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG EGFR GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81235","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81235","type":"HCPCS"}],"standard_charges":[{"gross_charge":1195.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG EZH2 GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81236","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81236","type":"HCPCS"}],"standard_charges":[{"gross_charge":860.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG EZH2 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81237","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81237","type":"HCPCS"}],"standard_charges":[{"gross_charge":534.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DMPK GENE ANALYSIS CHARACTERIZATION OF ALLELES","code_information":[{"code":"81239","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81239","type":"HCPCS"}],"standard_charges":[{"gross_charge":837.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG F2 GENE ANALYSIS 20210G >A VARIANT","code_information":[{"code":"81240","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81240","type":"HCPCS"}],"standard_charges":[{"gross_charge":268.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT","code_information":[{"code":"81241","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81241","type":"HCPCS"}],"standard_charges":[{"gross_charge":331.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FANCC GENE ANALYSIS COMMON VARIANT","code_information":[{"code":"81242","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81242","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FMR1 GENE ALYS EVAL TO DETECT ABNORMAL ALLELES","code_information":[{"code":"81243","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81243","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES","code_information":[{"code":"81244","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81244","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLT3 GENE ANALYSIS INTERNAL TANDEM DUP VARIANTS","code_information":[{"code":"81245","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81245","type":"HCPCS"}],"standard_charges":[{"gross_charge":514.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLT3 GENE ANLYS TYROSINE KINASE DOMAIN VARIANTS","code_information":[{"code":"81246","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81246","type":"HCPCS"}],"standard_charges":[{"gross_charge":258.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG G6PC GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81250","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81250","type":"HCPCS"}],"standard_charges":[{"gross_charge":379.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS","code_information":[{"code":"81251","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81251","type":"HCPCS"}],"standard_charges":[{"gross_charge":350.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GJB2 GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81252","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81252","type":"HCPCS"}],"standard_charges":[{"gross_charge":379.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEXA GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81255","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81255","type":"HCPCS"}],"standard_charges":[{"gross_charge":940.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS","code_information":[{"code":"81256","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81256","type":"HCPCS"}],"standard_charges":[{"gross_charge":339.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIANT","code_information":[{"code":"81257","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81257","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IKBKAP GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81260","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81260","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IGH@ REARRANGE ABNORMAL CLONAL POP AMPLIFIED","code_information":[{"code":"81261","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81261","type":"HCPCS"}],"standard_charges":[{"gross_charge":985.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IGH@ VARIABLE REGION SOMATIC MUTATION ANALYSIS","code_information":[{"code":"81263","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81263","type":"HCPCS"}],"standard_charges":[{"gross_charge":1583.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IGK@ GENE REARRANGE DETECT ABNORMAL CLONAL POP","code_information":[{"code":"81264","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81264","type":"HCPCS"}],"standard_charges":[{"gross_charge":441.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC","code_information":[{"code":"81265","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81265","type":"HCPCS"}],"standard_charges":[{"gross_charge":1452.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION","code_information":[{"code":"81267","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81267","type":"HCPCS"}],"standard_charges":[{"gross_charge":650.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA","code_information":[{"code":"81268","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81268","type":"HCPCS"}],"standard_charges":[{"gross_charge":817.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS","code_information":[{"code":"81269","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81269","type":"HCPCS"}],"standard_charges":[{"gross_charge":716.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG JAK2 GENE ANALYSIS P.VAL617PHE VARIANT","code_information":[{"code":"81270","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81270","type":"HCPCS"}],"standard_charges":[{"gross_charge":455.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HTT GENE ANALYSIS DETECT ABNORMAL ALLELES","code_information":[{"code":"81271","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81271","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG KIT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS","code_information":[{"code":"81272","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81272","type":"HCPCS"}],"standard_charges":[{"gross_charge":1195.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG KIT GENE ANALYSIS D816 VARIANT(S)","code_information":[{"code":"81273","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81273","type":"HCPCS"}],"standard_charges":[{"gross_charge":412.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HTT GENE ANALYSIS CHARACTERIZATION ALLELES","code_information":[{"code":"81274","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81274","type":"HCPCS"}],"standard_charges":[{"gross_charge":837.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS","code_information":[{"code":"81277","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81277","type":"HCPCS"}],"standard_charges":[{"gross_charge":3486.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG JAK2 TARGETED SEQUENCE ANALYSIS","code_information":[{"code":"81279","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81279","type":"HCPCS"}],"standard_charges":[{"gross_charge":670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FXN GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81284","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81284","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FXN GENE ANALYSIS CHARACTERIZATION ALLELES","code_information":[{"code":"81285","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81285","type":"HCPCS"}],"standard_charges":[{"gross_charge":837.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FXN GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81286","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81286","type":"HCPCS"}],"standard_charges":[{"gross_charge":892.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MGMT GENE PROMOTER METHYLATION ANALYSIS","code_information":[{"code":"81287","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81287","type":"HCPCS"}],"standard_charges":[{"gross_charge":387.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MLH1 GENE ANALYSIS PROMOTER METHYLATION ANALYSIS","code_information":[{"code":"81288","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81288","type":"HCPCS"}],"standard_charges":[{"gross_charge":597.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FXN GENE ANALYSIS KNOWN FAMILIAL VARIANTS","code_information":[{"code":"81289","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81289","type":"HCPCS"}],"standard_charges":[{"gross_charge":564.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MCOLN1 MUCOLIPIN1 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81290","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81290","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MTHFR GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81291","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81291","type":"HCPCS"}],"standard_charges":[{"gross_charge":286.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MLH1 GENE ANALYSIS FULL SEQUENCE ANALYSIS","code_information":[{"code":"81292","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81292","type":"HCPCS"}],"standard_charges":[{"gross_charge":2097.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MLH1 GENE ANALYSIS DUPLICATION/DELETION VARIANTS","code_information":[{"code":"81294","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81294","type":"HCPCS"}],"standard_charges":[{"gross_charge":628.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS","code_information":[{"code":"81295","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81295","type":"HCPCS"}],"standard_charges":[{"gross_charge":1185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MSH2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS","code_information":[{"code":"81297","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81297","type":"HCPCS"}],"standard_charges":[{"gross_charge":662.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS","code_information":[{"code":"81298","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81298","type":"HCPCS"}],"standard_charges":[{"gross_charge":1016.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MSH6 GENE ANALYSIS DUPLICATION/DELETION VARIA","code_information":[{"code":"81300","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81300","type":"HCPCS"}],"standard_charges":[{"gross_charge":635.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MYD88 GENE ANALYSIS P.LEU265 (L265P) VARIANT","code_information":[{"code":"81305","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81305","type":"HCPCS"}],"standard_charges":[{"gross_charge":569.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NUDT15 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81306","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81306","type":"HCPCS"}],"standard_charges":[{"gross_charge":942.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NPM1 NUCLEOPHOSMIN GENE ANAL EXON 12 VARIANTS","code_information":[{"code":"81310","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81310","type":"HCPCS"}],"standard_charges":[{"gross_charge":766.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PABPN1 GENE ANALYSIS EVAL DETC ABNORMAL ALLELES","code_information":[{"code":"81312","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81312","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PCA3/KLK3 PROSTATE SPECIFIC ANTIGEN RATIO","code_information":[{"code":"81313","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81313","type":"HCPCS"}],"standard_charges":[{"gross_charge":842.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PML/RARALPHA COMMON BREAKPOINTS QUAL/QUANT","code_information":[{"code":"81315","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81315","type":"HCPCS"}],"standard_charges":[{"gross_charge":694.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PMS2 GENE ANALYSIS FULL SEQUENCE","code_information":[{"code":"81317","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81317","type":"HCPCS"}],"standard_charges":[{"gross_charge":2101.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PMS2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS","code_information":[{"code":"81319","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81319","type":"HCPCS"}],"standard_charges":[{"gross_charge":632.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PLCG2 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81320","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81320","type":"HCPCS"}],"standard_charges":[{"gross_charge":884.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS","code_information":[{"code":"81321","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81321","type":"HCPCS"}],"standard_charges":[{"gross_charge":1800.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PMP22 GENE ANAL DUPLICATION/DELETION ANALYSIS","code_information":[{"code":"81324","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81324","type":"HCPCS"}],"standard_charges":[{"gross_charge":1229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMN1 GENE ANALYSIS DOSAGE/DELET ALYS W/SMN2 ALYS","code_information":[{"code":"81329","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81329","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMPD1 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81330","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81330","type":"HCPCS"}],"standard_charges":[{"gross_charge":243.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SNRPN/UBE3A METHYLATION ANALYSIS","code_information":[{"code":"81331","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81331","type":"HCPCS"}],"standard_charges":[{"gross_charge":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SERPINA1 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81332","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81332","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TGFBI GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81333","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81333","type":"HCPCS"}],"standard_charges":[{"gross_charge":416.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TPMT GENE ANALAYSIS COMMON VARIANTS","code_information":[{"code":"81335","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81335","type":"HCPCS"}],"standard_charges":[{"gross_charge":666.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMN1 GENE ANALYSIS FULL GENE SEQUENCE","code_information":[{"code":"81336","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81336","type":"HCPCS"}],"standard_charges":[{"gross_charge":975.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMN1 GENE ANALYSIS KNOWN FAMILIAL SEQ VARIANTS","code_information":[{"code":"81337","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81337","type":"HCPCS"}],"standard_charges":[{"gross_charge":564.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MPL GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81338","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81338","type":"HCPCS"}],"standard_charges":[{"gross_charge":467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10","code_information":[{"code":"81339","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81339","type":"HCPCS"}],"standard_charges":[{"gross_charge":670.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD","code_information":[{"code":"81340","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81340","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TRG@ GENE REARRANGEMENT ANALYSIS","code_information":[{"code":"81342","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81342","type":"HCPCS"}],"standard_charges":[{"gross_charge":1003.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PPP2R2B GENE ANALYSIS EVAL DETC ABNORMAL ALLELES","code_information":[{"code":"81343","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81343","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TBP GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES","code_information":[{"code":"81344","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81344","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TERT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS","code_information":[{"code":"81345","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81345","type":"HCPCS"}],"standard_charges":[{"gross_charge":564.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TYMS GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81346","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81346","type":"HCPCS"}],"standard_charges":[{"gross_charge":666.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UGT1A1 GENE ANALYSIS COMMON VARIANTS","code_information":[{"code":"81350","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81350","type":"HCPCS"}],"standard_charges":[{"gross_charge":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TP53 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS","code_information":[{"code":"81352","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81352","type":"HCPCS"}],"standard_charges":[{"gross_charge":2087.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HBB FULL GENE SEQUENCE","code_information":[{"code":"81364","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81364","type":"HCPCS"}],"standard_charges":[{"gross_charge":1244.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS I&II LOW HLA-A -B -C -DRB1/3/4/5&DQB","code_information":[{"code":"81370","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81370","type":"HCPCS"}],"standard_charges":[{"gross_charge":2054.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS I TYPING LOW RESOLUTION COMPLETE","code_information":[{"code":"81372","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81372","type":"HCPCS"}],"standard_charges":[{"gross_charge":1213.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS I TYPING LOW RESOLUTION ONE LOCUS EACH","code_information":[{"code":"81373","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81373","type":"HCPCS"}],"standard_charges":[{"gross_charge":554.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA I LOW RESOLUTION ONE ANTIGEN EQUIVALENT EACH","code_information":[{"code":"81374","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81374","type":"HCPCS"}],"standard_charges":[{"gross_charge":379.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA II LOW RESOLUTION HLA-DRB1/3/4/5 AND -DQB1","code_information":[{"code":"81375","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81375","type":"HCPCS"}],"standard_charges":[{"gross_charge":1125.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS II TYPING LOW RESOLUTION ONE LOCUS EA","code_information":[{"code":"81376","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81376","type":"HCPCS"}],"standard_charges":[{"gross_charge":635.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA II LOW RESOLUTION ONE ANTIGEN EQUIVALENT EA","code_information":[{"code":"81377","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81377","type":"HCPCS"}],"standard_charges":[{"gross_charge":483.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS I TYPING HIGH RESOLUTION COMPLETE","code_information":[{"code":"81379","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81379","type":"HCPCS"}],"standard_charges":[{"gross_charge":1717.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS I TYPING HIGH RESOLUTION ONE LOCUS EA","code_information":[{"code":"81380","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81380","type":"HCPCS"}],"standard_charges":[{"gross_charge":907.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA I TYPING HIGH RESOLUTION 1 ALLELE/ALLELE GRP","code_information":[{"code":"81381","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81381","type":"HCPCS"}],"standard_charges":[{"gross_charge":470.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CLASS II TYPING HIGH RESOLUTION ONE LOCUS EA","code_information":[{"code":"81382","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81382","type":"HCPCS"}],"standard_charges":[{"gross_charge":615.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA II HIGH RESOLUTION 1 ALLELE/ALLELE GROUP","code_information":[{"code":"81383","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81383","type":"HCPCS"}],"standard_charges":[{"gross_charge":568.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 1","code_information":[{"code":"81400","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81400","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 2","code_information":[{"code":"81401","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81401","type":"HCPCS"}],"standard_charges":[{"gross_charge":229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 3","code_information":[{"code":"81402","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81402","type":"HCPCS"}],"standard_charges":[{"gross_charge":229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 4","code_information":[{"code":"81403","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81403","type":"HCPCS"}],"standard_charges":[{"gross_charge":809.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 5","code_information":[{"code":"81404","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81404","type":"HCPCS"}],"standard_charges":[{"gross_charge":397.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 6","code_information":[{"code":"81405","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81405","type":"HCPCS"}],"standard_charges":[{"gross_charge":284.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 7","code_information":[{"code":"81406","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81406","type":"HCPCS"}],"standard_charges":[{"gross_charge":994.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 8","code_information":[{"code":"81407","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81407","type":"HCPCS"}],"standard_charges":[{"gross_charge":2584.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR PATHOLOGY PROCEDURE LEVEL 9","code_information":[{"code":"81408","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81408","type":"HCPCS"}],"standard_charges":[{"gross_charge":840.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AORTIC DYSFUNCTION/DILATION GENOMIC SEQ ANALYSIS","code_information":[{"code":"81410","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81410","type":"HCPCS"}],"standard_charges":[{"gross_charge":7214.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AORTIC DYSFUNCTION/DILATION DUP/DEL ANALYSIS","code_information":[{"code":"81411","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81411","type":"HCPCS"}],"standard_charges":[{"gross_charge":970.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASHKENAZI JEWISH ASSOC DSRDRS GEN SEQ ANAL 9 GEN","code_information":[{"code":"81412","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81412","type":"HCPCS"}],"standard_charges":[{"gross_charge":7382.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES","code_information":[{"code":"81414","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81414","type":"HCPCS"}],"standard_charges":[{"gross_charge":1816.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS","code_information":[{"code":"81420","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81420","type":"HCPCS"}],"standard_charges":[{"gross_charge":2968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEREDITARY BRST CA-RLATD DO GEN SEQ ALYS 5+ GEN","code_information":[{"code":"81432","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81432","type":"HCPCS"}],"standard_charges":[{"gross_charge":4049.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEREDITARY COLON CA-RELATED DO GEN SEQ ALYS 5+","code_information":[{"code":"81435","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81435","type":"HCPCS"}],"standard_charges":[{"gross_charge":4049.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HERED NEUROEND TUM-RELATED DO GEN SEQ ALYS 5+","code_information":[{"code":"81437","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81437","type":"HCPCS"}],"standard_charges":[{"gross_charge":4049.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEREDITARY CARDIOMYOPATHY GEN SEQ ANALYS 5 GEN","code_information":[{"code":"81439","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81439","type":"HCPCS"}],"standard_charges":[{"gross_charge":1856.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NUCLEAR MITOCHONDRIAL 100 GENE GENOMIC SEQ","code_information":[{"code":"81440","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81440","type":"HCPCS"}],"standard_charges":[{"gross_charge":9972.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GENETIC TESTING FOR SEVERE INHERITED CONDITIONS","code_information":[{"code":"81443","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81443","type":"HCPCS"}],"standard_charges":[{"gross_charge":7903.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SOLID ORGAN NEOPLASM GSAP 5-50 DNA/DNA&RNA ALYS","code_information":[{"code":"81445","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81445","type":"HCPCS"}],"standard_charges":[{"gross_charge":1978.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEREDITARY PERIPHERAL NEUROPATHY GEN SEQ PNL","code_information":[{"code":"81448","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81448","type":"HCPCS"}],"standard_charges":[{"gross_charge":7223.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMATOLYMPHOID NEO/DO GSAP 5-50DNA/DNA&RNA ALYS","code_information":[{"code":"81450","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81450","type":"HCPCS"}],"standard_charges":[{"gross_charge":2359.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SO/HEMATOLYMPHOID NEO/DO 51/>GSAP DNA/DNA&RNA","code_information":[{"code":"81455","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81455","type":"HCPCS"}],"standard_charges":[{"gross_charge":17230.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SO NEO GSAP DNA ALYS MICROSATELLITE INSTABILITY","code_information":[{"code":"81457","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81457","type":"HCPCS"}],"standard_charges":[{"gross_charge":2785.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SO NEO GSAP DNA ALYS/DNA&RNA CPY NMBR MCRSTL INS","code_information":[{"code":"81459","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81459","type":"HCPCS"}],"standard_charges":[{"gross_charge":9283.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG WHOLE MITOCHONDRIAL GENOME","code_information":[{"code":"81460","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81460","type":"HCPCS"}],"standard_charges":[{"gross_charge":3861.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SO NEO GSAP CL FR DNA/DNA&RNA CPY NMBR MCRST INS","code_information":[{"code":"81464","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81464","type":"HCPCS"}],"standard_charges":[{"gross_charge":10298.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG WHOLE MITOCHONDRIAL GENOME ANALYSIS PANEL","code_information":[{"code":"81465","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81465","type":"HCPCS"}],"standard_charges":[{"gross_charge":2808.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UNLISTED MOLECULAR PATHOLOGY PROCEDURE","code_information":[{"code":"81479","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AUTOIMMUNE RHEUMATOID ARTHRITIS ALYS 12 BMRK","code_information":[{"code":"81490","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81490","type":"HCPCS"}],"standard_charges":[{"gross_charge":2570.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS","code_information":[{"code":"81500","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81500","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS","code_information":[{"code":"81503","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81503","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS","code_information":[{"code":"81508","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81508","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT DS BACTERAL VAGINOSIS RNA VAGINAL-FLUID ALG","code_information":[{"code":"81513","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81513","type":"HCPCS"}],"standard_charges":[{"gross_charge":498.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT DS BCT VAGINOSIS&VAGINITIS DNA VAG FLU ALG","code_information":[{"code":"81514","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81514","type":"HCPCS"}],"standard_charges":[{"gross_charge":831.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS","code_information":[{"code":"81515","type":"CDM"},{"code":"0300","type":"RC"},{"code":"81515","type":"HCPCS"}],"standard_charges":[{"gross_charge":817.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG","code_information":[{"code":"81517","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81517","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONCOLOGY BREAST MRNA GENE EXPRESSION 11 GENES","code_information":[{"code":"81518","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81518","type":"HCPCS"}],"standard_charges":[{"gross_charge":11732.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONCOLOGY PROSTATE BIOCHEMICAL ASSAY 4 PROTEINS","code_information":[{"code":"81539","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81539","type":"HCPCS"}],"standard_charges":[{"gross_charge":2354.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONC PRST8 MRNA MICRORA GENE XPRSN PRFL 22 GENES","code_information":[{"code":"81542","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81542","type":"HCPCS"}],"standard_charges":[{"gross_charge":12026.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TRNSPLN REJ KDN MRNA GENE XPRSN PRFLG QPCR 139","code_information":[{"code":"81558","type":"CDM"},{"code":"0300","type":"RC"},{"code":"81558","type":"HCPCS"}],"standard_charges":[{"gross_charge":10060.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR","code_information":[{"code":"81596","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81596","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS","code_information":[{"code":"81599","type":"CDM"},{"code":"0310","type":"RC"},{"code":"81599","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG KETONE BODYS QUALITATIVE","code_information":[{"code":"82009","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82009","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG KETONE BODYS QUANTITATIVE","code_information":[{"code":"82010","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82010","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACYLCARNITINES QUANTIATIVE EACH SPECIMEN","code_information":[{"code":"82017","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82017","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ADRENOCORTICOTROPIC HORMONE ACTH","code_information":[{"code":"82024","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82024","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ADENOSINE 5-MONOPHOSPHATE CYCLIC","code_information":[{"code":"82030","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82030","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALBUMIN SERUM PLASMA/WHOLE BLOOD","code_information":[{"code":"82040","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82040","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OTHER SOURCE ALBUMIN QUANTITATIVE EACH SPECIMEN","code_information":[{"code":"82042","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82042","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URINE ALBUMIN QUANTITATIVE","code_information":[{"code":"82043","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82043","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG URINE ALBUMIN SEMIQUANTITATIVE","code_information":[{"code":"82044","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82044","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ALCOHOL (ETHANOL) SPEC XCP UR&BREATH IA","code_information":[{"code":"82077","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82077","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ALDOLASE","code_information":[{"code":"82085","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82085","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ALDOSTERONE","code_information":[{"code":"82088","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82088","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALPHA-1-ANTITRYPSIN TOTAL","code_information":[{"code":"82103","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82103","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALPHA-1-ANTITRYPSIN PHENOTYPE","code_information":[{"code":"82104","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82104","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALPHA-FETOPROTEIN SERUM","code_information":[{"code":"82105","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82105","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AFP-L3 FRACTION ISOFORM & TOTAL AFP W/RATIO","code_information":[{"code":"82107","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82107","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ALUMINUM","code_information":[{"code":"82108","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82108","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AMINO ACIDS 1 QUANTITATIVE EACH SPECIMEN","code_information":[{"code":"82131","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82131","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AMINOLEVULINIC ACID DELTA","code_information":[{"code":"82135","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82135","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AMINO ACIDS 6/> AMINO ACIDS QUANTITATIVE EA SPE","code_information":[{"code":"82139","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82139","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF AMMONIA","code_information":[{"code":"82140","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82140","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF AMYLASE","code_information":[{"code":"82150","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82150","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANDROSTENEDIONE","code_information":[{"code":"82157","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82157","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANGIOTENSIN I-CONVERTING ENZYME","code_information":[{"code":"82164","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82164","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ANTI-MULLERIAN HORMONE","code_information":[{"code":"82166","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82166","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG APOLIPOPROTEIN EACH","code_information":[{"code":"82172","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82172","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ARSENIC","code_information":[{"code":"82175","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82175","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ASCORBIC ACID BLOOD","code_information":[{"code":"82180","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82180","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BETA-2 MICROGLOBULIN","code_information":[{"code":"82232","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82232","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BETA-AMYLOID 1-40 (ABETA 40)","code_information":[{"code":"82233","type":"CDM"},{"code":"0300","type":"RC"},{"code":"82233","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BETA-AMYLOID 1-42 (ABETA 42)","code_information":[{"code":"82234","type":"CDM"},{"code":"0300","type":"RC"},{"code":"82234","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BILE ACIDS TOTAL","code_information":[{"code":"82239","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82239","type":"HCPCS"}],"standard_charges":[{"gross_charge":347.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BILIRUBIN TOTAL","code_information":[{"code":"82247","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82247","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BILIRUBIN DIRECT","code_information":[{"code":"82248","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82248","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BIOTINIDASE EACH SPECIMEN","code_information":[{"code":"82261","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82261","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER","code_information":[{"code":"82270","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82270","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD OCCULT PEROXIDASE ACTV QUAL OTHER SOURCES","code_information":[{"code":"82271","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82271","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC","code_information":[{"code":"82272","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82272","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3","code_information":[{"code":"82274","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82274","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CADMIUM","code_information":[{"code":"82300","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82300","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED","code_information":[{"code":"82306","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82306","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALCITONIN","code_information":[{"code":"82308","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82308","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALCIUM TOTAL","code_information":[{"code":"82310","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82310","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALCIUM IONIZED","code_information":[{"code":"82330","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82330","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALCIUM URINE QUANTITATIVE TIMED SPECIMEN","code_information":[{"code":"82340","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82340","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALCULUS QUANTITATIVE CHEMICAL","code_information":[{"code":"82360","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82360","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CALCULUS INFRARED SPECTROSCOPY","code_information":[{"code":"82365","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82365","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CARBOHYDRATE DEFICIENT TRANSFERRIN","code_information":[{"code":"82373","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82373","type":"HCPCS"}],"standard_charges":[{"gross_charge":355.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CARBON DIOXIDE BICARBONATE","code_information":[{"code":"82374","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82374","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CARBOXYHEMOGLOBIN QUANTITATIVE","code_information":[{"code":"82375","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82375","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CARCINOEMBRYONIC ANTIGEN CEA","code_information":[{"code":"82378","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82378","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CARNITINE QUANTITATIVE EACH SPECIMEN","code_information":[{"code":"82379","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82379","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CAROTENE","code_information":[{"code":"82380","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82380","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CATECHOLAMINES TOTAL URINE","code_information":[{"code":"82382","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82382","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CATECHOLAMINES FRACTIONATED","code_information":[{"code":"82384","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82384","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CERULOPLASMIN","code_information":[{"code":"82390","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82390","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHEMILUMINESCENT ASSAY","code_information":[{"code":"82397","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82397","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHLORIDE BLD","code_information":[{"code":"82435","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82435","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHLORIDE URINE","code_information":[{"code":"82436","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82436","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHLORIDE OTHER SOURCE","code_information":[{"code":"82438","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82438","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHLORINATED HYDROCARBONS SCREEN","code_information":[{"code":"82441","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82441","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHOLESTEROL SERUM/WHOLE BLOOD TOTAL","code_information":[{"code":"82465","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82465","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHOLINESTERASE SERUM","code_information":[{"code":"82480","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82480","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHOLINESTERASE RBC","code_information":[{"code":"82482","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82482","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF CHROMIUM","code_information":[{"code":"82495","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82495","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF CITRATE","code_information":[{"code":"82507","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82507","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COLLAGEN CROSS LINKS ANY METHOD","code_information":[{"code":"82523","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82523","type":"HCPCS"}],"standard_charges":[{"gross_charge":505.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF COPPER","code_information":[{"code":"82525","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82525","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CORTISOL FREE","code_information":[{"code":"82530","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82530","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CORTISOL TOTAL","code_information":[{"code":"82533","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC","code_information":[{"code":"82542","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CREATINE KINASE TOTAL","code_information":[{"code":"82550","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82550","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CREATINE KINASE ISOENZYMES","code_information":[{"code":"82552","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82552","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CREATINE KINASE MB FRACTION ONLY","code_information":[{"code":"82553","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82553","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CREATININE BLOOD","code_information":[{"code":"82565","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82565","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CREATININE OTHER SOURCE","code_information":[{"code":"82570","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82570","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CREATININE CLEARANCE","code_information":[{"code":"82575","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82575","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF CRYOFIBRN","code_information":[{"code":"82585","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82585","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE","code_information":[{"code":"82595","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82595","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF CYANIDE","code_information":[{"code":"82600","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82600","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYANOCOBALAMIN VITAMIN B-12","code_information":[{"code":"82607","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82607","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYANOCOBALAMIN VIT B-12 UNSAT BINDING CAPACITY","code_information":[{"code":"82608","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82608","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYSTATIN C","code_information":[{"code":"82610","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82610","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DEHYDROEPIANDROSTERONE","code_information":[{"code":"82626","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82626","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DEHYDROEPIANDROSTERONE-SULFATE","code_information":[{"code":"82627","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82627","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DEOXYCORTISOL 11-","code_information":[{"code":"82634","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82634","type":"HCPCS"}],"standard_charges":[{"gross_charge":376.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF DIBUCAINE NUMBER","code_information":[{"code":"82638","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82638","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DIHYDROTESTOSTERONE (DHT)","code_information":[{"code":"82642","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82642","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG 1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED","code_information":[{"code":"82652","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82652","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ELASTASE PANCREATIC FECAL QUANTITATIVE","code_information":[{"code":"82653","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82653","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ELASTASE PANCREATIC FECAL QUAL/SEMI-QUANTITATIVE","code_information":[{"code":"82656","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82656","type":"HCPCS"}],"standard_charges":[{"gross_charge":526.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE EA","code_information":[{"code":"82657","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82657","type":"HCPCS"}],"standard_charges":[{"gross_charge":611.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NZYM ACTV BLOOD CELLS/TISS RADACT SUBSTRATE EA","code_information":[{"code":"82658","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82658","type":"HCPCS"}],"standard_charges":[{"gross_charge":597.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ELCTROPHORETIC TECHNIQUE NOT ELSEWHERE SPECIFIED","code_information":[{"code":"82664","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82664","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ERYTHROPOIETIN","code_information":[{"code":"82668","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82668","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TOTAL ESTRADIOL","code_information":[{"code":"82670","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82670","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ESTROGENS FRACTIONATED","code_information":[{"code":"82671","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82671","type":"HCPCS"}],"standard_charges":[{"gross_charge":548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ESTROGENS TOTAL","code_information":[{"code":"82672","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82672","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ESTRIOL","code_information":[{"code":"82677","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82677","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ESTRONE","code_information":[{"code":"82679","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82679","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF DIRECT MEASUREMENT FREE ESTRADIOL","code_information":[{"code":"82681","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82681","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ETHYLENE GLYCOL","code_information":[{"code":"82693","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82693","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FAT/LIPIDS FECES QUALITATIVE","code_information":[{"code":"82705","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82705","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FAT/LIPIDS FECES QUANTITATIVE","code_information":[{"code":"82710","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82710","type":"HCPCS"}],"standard_charges":[{"gross_charge":334.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FATTY ACIDS NONESTERIFIED","code_information":[{"code":"82725","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82725","type":"HCPCS"}],"standard_charges":[{"gross_charge":520.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VERY LONG CHAIN FATTY ACIDS","code_information":[{"code":"82726","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82726","type":"HCPCS"}],"standard_charges":[{"gross_charge":618.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF FERRITIN","code_information":[{"code":"82728","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82728","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FTL FIBRONECTIN CERVICOVAG SECRETIONS SEMI-QUAN","code_information":[{"code":"82731","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82731","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF FLUORIDE","code_information":[{"code":"82735","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82735","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF FOLIC ACID SERUM","code_information":[{"code":"82746","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82746","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF FOLIC ACID RBC","code_information":[{"code":"82747","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82747","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF FRUCTOSE SEMEN","code_information":[{"code":"82757","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82757","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE QUAN","code_information":[{"code":"82775","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82775","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GALECTIN-3","code_information":[{"code":"82777","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82777","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH","code_information":[{"code":"82784","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GAMMAGLOBULIN IGE","code_information":[{"code":"82785","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82785","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLASSES","code_information":[{"code":"82787","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82787","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GASES BLOOD PH ONLY","code_information":[{"code":"82800","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82800","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3","code_information":[{"code":"82803","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82803","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY","code_information":[{"code":"82805","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN","code_information":[{"code":"82820","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82820","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GASTRIN AFTER SECRETIN STIMULATION","code_information":[{"code":"82938","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82938","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GASTRIN","code_information":[{"code":"82941","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82941","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GLUCAGON","code_information":[{"code":"82943","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82943","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE BODY FLUID OTHER THAN BLOOD","code_information":[{"code":"82945","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82945","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP","code_information":[{"code":"82947","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82947","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE BLOOD REAGENT STRIP","code_information":[{"code":"82948","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82948","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE POST GLUCOSE DOSE","code_information":[{"code":"82950","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82950","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE TOLERANCE TEST GTT 3 SPECIMENS","code_information":[{"code":"82951","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82951","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS","code_information":[{"code":"82952","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82952","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE","code_information":[{"code":"82955","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82955","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN","code_information":[{"code":"82960","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82960","type":"HCPCS"}],"standard_charges":[{"gross_charge":19.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE","code_information":[{"code":"82962","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82962","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GLUTAMYLTRASE GAMMA","code_information":[{"code":"82977","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82977","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GLUTATHIONE","code_information":[{"code":"82978","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82978","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GLYCATED PROTEIN","code_information":[{"code":"82985","type":"CDM"},{"code":"0301","type":"RC"},{"code":"82985","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GONADOTROPIN FOLLICLE STIMULATING HORMONE","code_information":[{"code":"83001","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83001","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GONADOTROPIN LUTEINIZING HORMONE","code_information":[{"code":"83002","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83002","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF GROWTH HORMONE HUMAN","code_information":[{"code":"83003","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83003","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HAPTOGLOBIN QUANTITATIVE","code_information":[{"code":"83010","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83010","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE","code_information":[{"code":"83013","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83013","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEAVY METAL QUANTIATIVE EACH NES","code_information":[{"code":"83018","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83018","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN FRACTJ/QUANTJ ELECTROPHORESIS","code_information":[{"code":"83020","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83020","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN FRACTJ/QUANTJ CHROMOTOGRAPHY","code_information":[{"code":"83021","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83021","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN COPPER SULFATE METHOD NON-AUTOMATED","code_information":[{"code":"83026","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83026","type":"HCPCS"}],"standard_charges":[{"gross_charge":19.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN F FETAL CHEMICAL","code_information":[{"code":"83030","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83030","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN F FETAL QUALITATIVE","code_information":[{"code":"83033","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83033","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN GLYCOSYLATED A1C","code_information":[{"code":"83036","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83036","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE","code_information":[{"code":"83050","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83050","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOGLOBIN PLASMA","code_information":[{"code":"83051","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83051","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HEMOSIDERIN QUALITATIVE","code_information":[{"code":"83070","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83070","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF B-HEXOSAMINIDASE EACH ASSAY","code_information":[{"code":"83080","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83080","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HISTAMINE","code_information":[{"code":"83088","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83088","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HOMOCYSTEINE","code_information":[{"code":"83090","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83090","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HOMOVANILLIC ACID","code_information":[{"code":"83150","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83150","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HYDROXYCORTICOSTEROIDS 17","code_information":[{"code":"83491","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83491","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA","code_information":[{"code":"83497","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83497","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF HYDROXYPROGESTERONE 17-D","code_information":[{"code":"83498","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83498","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY ANALYTE QUAL/SEMIQUAN MULTIPLE STEP","code_information":[{"code":"83516","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY ANALYTE QUAL/SEMIQUAL SINGLE STEP","code_information":[{"code":"83518","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83518","type":"HCPCS"}],"standard_charges":[{"gross_charge":30.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY","code_information":[{"code":"83519","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY ANALYTE QUANTITATIVE NOS","code_information":[{"code":"83520","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOGLOBULIN LIGHT CHAINS FREE EACH","code_information":[{"code":"83521","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83521","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF INSULIN TOTAL","code_information":[{"code":"83525","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83525","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF INSULIN FREE","code_information":[{"code":"83527","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83527","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF INTERLEUKIN-6 (IL-6)","code_information":[{"code":"83529","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83529","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF IRON","code_information":[{"code":"83540","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83540","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IRON BINDING CAPACITY","code_information":[{"code":"83550","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83550","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF KETOSTEROIDS 17- TOTAL","code_information":[{"code":"83586","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83586","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF LACTATE","code_information":[{"code":"83605","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83605","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LACTATE DEHYDROGENASE LDH","code_information":[{"code":"83615","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83615","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LACTATE DEHYDROGENASE ISOENZYMES SEP&QUAN","code_information":[{"code":"83625","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83625","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LACTOFERRIN FECAL QUALITATIVE","code_information":[{"code":"83630","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83630","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LACTOFERRIN FECAL QUANTITATIVE","code_information":[{"code":"83631","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83631","type":"HCPCS"}],"standard_charges":[{"gross_charge":330.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF LEAD","code_information":[{"code":"83655","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83655","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FETAL LUNG MATURITY LECITHIN SPHINGOMYELIN RATIO","code_information":[{"code":"83661","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83661","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FETAL LUNG MATURITY LAMELLAR BODY DENSITY","code_information":[{"code":"83664","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83664","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEUCINE AMINOPEPTIDASE LAP","code_information":[{"code":"83670","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83670","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF LIPASE","code_information":[{"code":"83690","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83690","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN (A)","code_information":[{"code":"83695","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83695","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2","code_information":[{"code":"83698","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83698","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN","code_information":[{"code":"83700","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83700","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN BLOOD HIGH RESOLTJ&QUANTJ SUBCLASS","code_information":[{"code":"83701","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83701","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN BLOOD QUAN NUMBERS & SUBCLASSES","code_information":[{"code":"83704","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83704","type":"HCPCS"}],"standard_charges":[{"gross_charge":327.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL","code_information":[{"code":"83718","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83718","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN DIRECT MEASUREMENT VLDL CHOLESTEROL","code_information":[{"code":"83719","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83719","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL","code_information":[{"code":"83721","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83721","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DIR MEAS LIPOPROTEIN SMALL DENSE LDL CHOLESTEROL","code_information":[{"code":"83722","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83722","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LUTEINIZING RELEASING FACTOR","code_information":[{"code":"83727","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83727","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF MAGNESIUM","code_information":[{"code":"83735","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83735","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF MANGANESE","code_information":[{"code":"83785","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83785","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MASS SPECT&TANDEM MASS SPECT NONDRG ANAL NES EA","code_information":[{"code":"83789","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83789","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF MERCURY QUANTITATIVE","code_information":[{"code":"83825","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83825","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG METANEPHRINES","code_information":[{"code":"83835","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83835","type":"HCPCS"}],"standard_charges":[{"gross_charge":393.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MUCOPOLYSACCHARIDES ACID QUANTITATIVE","code_information":[{"code":"83864","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83864","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MYELIN BASIC PROTEIN CEREBROSPINAL FLUID","code_information":[{"code":"83873","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83873","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MYOGLOBIN","code_information":[{"code":"83874","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83874","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NATRIURETIC PEPTIDE","code_information":[{"code":"83880","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83880","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF NEPHELOMETRY EACH ANALYTE NES","code_information":[{"code":"83883","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83883","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY NEUROFILAMENT LIGHT CHAIN","code_information":[{"code":"83884","type":"CDM"},{"code":"0300","type":"RC"},{"code":"83884","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF NICKEL","code_information":[{"code":"83885","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83885","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF NUCLEOTIDASE 5'-","code_information":[{"code":"83915","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83915","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OLIGOCLONAL IMMUNE","code_information":[{"code":"83916","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83916","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ORGANIC ACIDS TOTAL QUANTITATIVE EACH SPECIMEN","code_information":[{"code":"83918","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83918","type":"HCPCS"}],"standard_charges":[{"gross_charge":516.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ORGANIC ACIDS QUALITATIVE EACH SPECIMEN","code_information":[{"code":"83919","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83919","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ORGANIC ACID 1 QUANTITATIVE","code_information":[{"code":"83921","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83921","type":"HCPCS"}],"standard_charges":[{"gross_charge":360.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF OSMOLALITY BLOOD","code_information":[{"code":"83930","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83930","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF OSMOLALITY URINE","code_information":[{"code":"83935","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83935","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF OSTEOCALCIN","code_information":[{"code":"83937","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83937","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF OXALATE","code_information":[{"code":"83945","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83945","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ONCOPROTEIN DES-GAMMA-CARBOXY-PROTHROMBIN DCP","code_information":[{"code":"83951","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83951","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PARATHORMONE","code_information":[{"code":"83970","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83970","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PH BODY FLUID NOT ELSEWHERE SPECIFIED","code_information":[{"code":"83986","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83986","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHENCYCLIDINE","code_information":[{"code":"83992","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83992","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF CALPROTECTIN FECAL","code_information":[{"code":"83993","type":"CDM"},{"code":"0301","type":"RC"},{"code":"83993","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHENYLALANINE BLOOD","code_information":[{"code":"84030","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84030","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHATASE ACID TOTAL","code_information":[{"code":"84060","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84060","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHATASE ACID PROSTATIC","code_information":[{"code":"84066","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84066","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHATASE ALKALINE","code_information":[{"code":"84075","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84075","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHATASE ALKALINE ISOENZYMES","code_information":[{"code":"84080","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84080","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PHOSPHATIDYLGLYCEROL","code_information":[{"code":"84081","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84081","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHOHEXOSE ISOMERASE","code_information":[{"code":"84087","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84087","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHORUS INORGANIC","code_information":[{"code":"84100","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84100","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PHOSPHORUS INORGANIC URINE","code_information":[{"code":"84105","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84105","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PORPHOBILINOGEN URINE QUANTITATIVE","code_information":[{"code":"84110","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84110","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG EVAL C/V AMNIOTIC FLUID PROTEIN QUAL EA SPECIMEN","code_information":[{"code":"84112","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84112","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PORPHYRINS URINE QUANTITATION & FRACTIONATION","code_information":[{"code":"84120","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84120","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PORPHYRINS FECES QUANTITATIVE","code_information":[{"code":"84126","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84126","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG POTASSIUM SERUM PLASMA/WHOLE BLOOD","code_information":[{"code":"84132","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84132","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG POTASSIUM URINE","code_information":[{"code":"84133","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84133","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PREALBUMIN","code_information":[{"code":"84134","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84134","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PREGNANETRIOL","code_information":[{"code":"84138","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84138","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PREGNENOLONE","code_information":[{"code":"84140","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84140","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG 17-HYDROXYPREGNENOLONE","code_information":[{"code":"84143","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84143","type":"HCPCS"}],"standard_charges":[{"gross_charge":491.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROGESTERONE","code_information":[{"code":"84144","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84144","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROCALCITONIN (PCT)","code_information":[{"code":"84145","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84145","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROLACTIN","code_information":[{"code":"84146","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84146","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROSTAGLNDIN EACH","code_information":[{"code":"84150","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84150","type":"HCPCS"}],"standard_charges":[{"gross_charge":1201.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN COMPLEXED","code_information":[{"code":"84152","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84152","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL","code_information":[{"code":"84153","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84153","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE","code_information":[{"code":"84154","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84154","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD","code_information":[{"code":"84155","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84155","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN TOTAL XCPT REFRACTOMETRY URINE","code_information":[{"code":"84156","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84156","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC","code_information":[{"code":"84157","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84157","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN TOTAL REFRACTOMETRY ANY SRC","code_information":[{"code":"84160","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84160","type":"HCPCS"}],"standard_charges":[{"gross_charge":17.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PREGNANCY-ASSOCIATED PLASMA PROTEIN-A","code_information":[{"code":"84163","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84163","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM","code_information":[{"code":"84165","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84165","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATI","code_information":[{"code":"84166","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84166","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN WESTRN BLOT I&R BLOOD/OTHER FLUID","code_information":[{"code":"84181","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84181","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTEIN WESTRN BLOT BLOOD/OTH FLU IMMUNOLOGICAL","code_information":[{"code":"84182","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84182","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTOPORPHYRIN RBC QUANTITATIVE","code_information":[{"code":"84202","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84202","type":"HCPCS"}],"standard_charges":[{"gross_charge":369.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PROINSULIN","code_information":[{"code":"84206","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84206","type":"HCPCS"}],"standard_charges":[{"gross_charge":317.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PYRIDOXAL PHOSPHATE","code_information":[{"code":"84207","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84207","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PYRUVATE","code_information":[{"code":"84210","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84210","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF PYRUVATE KINASE","code_information":[{"code":"84220","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84220","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG RECEPTOR ASSAY NON-ENDOCRINE SPECIFY RECEPTOR","code_information":[{"code":"84238","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84238","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF RENIN","code_information":[{"code":"84244","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84244","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF RIBOFLAVIN-VITAMIN B-2","code_information":[{"code":"84252","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84252","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SELENIUM","code_information":[{"code":"84255","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84255","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SEROTONIN","code_information":[{"code":"84260","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84260","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SEX HORMONE BINDING GLOBULIN","code_information":[{"code":"84270","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84270","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SILICA","code_information":[{"code":"84285","type":"CDM"},{"code":"0309","type":"RC"},{"code":"84285","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SODIUM SERUM PLASMA OR WHOLE BLOOD","code_information":[{"code":"84295","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84295","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF URINE SODIUM","code_information":[{"code":"84300","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84300","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SODIUM OTHER SOURCE","code_information":[{"code":"84302","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84302","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SOMATOMEDIN","code_information":[{"code":"84305","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84305","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SOMATOSTATIN","code_information":[{"code":"84307","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84307","type":"HCPCS"}],"standard_charges":[{"gross_charge":447.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SPECTROPHOTOMETRY ANALYT NOT ELSEWHERE SPECIFIED","code_information":[{"code":"84311","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SPECIFIC GRAVITY EXCEPT URINE","code_information":[{"code":"84315","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84315","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SUGARS MONO DI&OLIGOS 1 QUALITATAIVE EACH SPEC","code_information":[{"code":"84376","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84376","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF SULFATE URINE","code_information":[{"code":"84392","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84392","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TAU PHOSPHORYLATED EACH","code_information":[{"code":"84393","type":"CDM"},{"code":"0300","type":"RC"},{"code":"84393","type":"HCPCS"}],"standard_charges":[{"gross_charge":26.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TOTAL TAU (TTAU)","code_information":[{"code":"84394","type":"CDM"},{"code":"0300","type":"RC"},{"code":"84394","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TESTOSTERONE FREE","code_information":[{"code":"84402","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84402","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TESTOSTERONE TOTAL","code_information":[{"code":"84403","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84403","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY BIOVLBL TESTOSTERONE DIRECT MEASUREMENT","code_information":[{"code":"84410","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84410","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF THIAMINE-VITAMIN B-1","code_information":[{"code":"84425","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84425","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF THIOCYANATE","code_information":[{"code":"84430","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84430","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THROMBOXANE METABOLITE W/WO THROMBOXANE URINE","code_information":[{"code":"84431","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84431","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF THYROGLOBULIN","code_information":[{"code":"84432","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84432","type":"HCPCS"}],"standard_charges":[{"gross_charge":72.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY THIOPURINE S-METHYLTRANSFERASE","code_information":[{"code":"84433","type":"CDM"},{"code":"0310","type":"RC"},{"code":"84433","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF THYROXINE TOTAL","code_information":[{"code":"84436","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84436","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF FREE THYROXINE","code_information":[{"code":"84439","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84439","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF THYROXINE BINDING GLOBULIN","code_information":[{"code":"84442","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84442","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF THYROID STIMULATING HORMONE TSH","code_information":[{"code":"84443","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84443","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THYROID STIMULATING IMMUNE GLOBULINS TSI","code_information":[{"code":"84445","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84445","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TOCOPHEROL ALPHA VITAMIN E","code_information":[{"code":"84446","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84446","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TRANSCORTIN CORTISOL BINDING GLOBULIN","code_information":[{"code":"84449","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84449","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TRANSFERASE ASPARTATE AMINO AST SGOT","code_information":[{"code":"84450","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84450","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TRANSFERASE ALANINE AMINO ALT SGPT","code_information":[{"code":"84460","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84460","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF L7383TRANSFERRIN","code_information":[{"code":"84466","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84466","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TRIGLYCERIDES","code_information":[{"code":"84478","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84478","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THYROID HORM UPTK/THYROID HORMONE BINDING RATIO","code_information":[{"code":"84479","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84479","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TRIIODOTHYRONINE T3 TOTAL TT3","code_information":[{"code":"84480","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84480","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TRIIODOTHYRONINE T3 FREE","code_information":[{"code":"84481","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84481","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TRIIODOTHYRONINE T3 REVERSE","code_information":[{"code":"84482","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84482","type":"HCPCS"}],"standard_charges":[{"gross_charge":396.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TROPONIN QUANTITATIVE","code_information":[{"code":"84484","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84484","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF TYROSINE","code_information":[{"code":"84510","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84510","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF UREA NITROGEN QUANTITATIVE","code_information":[{"code":"84520","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF UREA NITROGEN URINE","code_information":[{"code":"84540","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84540","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF BLOOD/URIC ACID","code_information":[{"code":"84550","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84550","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF URIC ACID OTHER SOURCE","code_information":[{"code":"84560","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84560","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VANILLYLMANDELIC ACID URINE","code_information":[{"code":"84585","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84585","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VASOACTIVE INTESTINAL PEPTIDE","code_information":[{"code":"84586","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84586","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VASOPRESSIN ANTI-DIURETIC HORMONE","code_information":[{"code":"84588","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84588","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VITAMIN A","code_information":[{"code":"84590","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84590","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED","code_information":[{"code":"84591","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84591","type":"HCPCS"}],"standard_charges":[{"gross_charge":562.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VITAMIN K","code_information":[{"code":"84597","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84597","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF VOLATILES","code_information":[{"code":"84600","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84600","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG XYLOSE ABSORPTION TEST BLOOD &/URINE","code_information":[{"code":"84620","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84620","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF ZINC","code_information":[{"code":"84630","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84630","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ASSAY OF C-PEPTIDE","code_information":[{"code":"84681","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84681","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GONADOTROPIN CHORIONIC QUANTITATIVE","code_information":[{"code":"84702","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84702","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GONADOTROPIN CHORIONIC QUALITATIVE","code_information":[{"code":"84703","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84703","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GONADOTROPIN CHORIONIC HCG FREE BETA CHAIN","code_information":[{"code":"84704","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84704","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UNLISTED CHEMISTRY PROCEDURE","code_information":[{"code":"84999","type":"CDM"},{"code":"0301","type":"RC"},{"code":"84999","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLEEDING TIME TEST","code_information":[{"code":"85002","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85002","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT AUTOMATED DIFFERENTIAL WBC COUNT","code_information":[{"code":"85004","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85004","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT SMEAR MCRSCP W/MNL DIFRNTL WBC COUNT","code_information":[{"code":"85007","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85007","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLD COUNT SMEAR MCRSCP W/O MNL DIFRNTL WBC COUNT","code_information":[{"code":"85008","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85008","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT MANUAL DIFRNTL WBC COUNT BUFFY COAT","code_information":[{"code":"85009","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85009","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT SPUN MICROHEMATOCRIT","code_information":[{"code":"85013","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85013","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT HEMATOCRIT","code_information":[{"code":"85014","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85014","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT HEMOGLOBIN","code_information":[{"code":"85018","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85018","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC","code_information":[{"code":"85025","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85025","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT COMPLETE AUTOMATED","code_information":[{"code":"85027","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85027","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT RED BLOOD CELL AUTOMATED","code_information":[{"code":"85041","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85041","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT RETICULOCYTE MANUAL","code_information":[{"code":"85044","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85044","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT RETICULOCYTE AUTOMATED","code_information":[{"code":"85045","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85045","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT RETICULOCYTES AUTO 1/> CELL MEAS","code_information":[{"code":"85046","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85046","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT LEUKOCYTE WBC AUTOMATED","code_information":[{"code":"85048","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85048","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD COUNT PLATELET AUTOMATED","code_information":[{"code":"85049","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85049","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG RETICULATED PLATELET ASSAY","code_information":[{"code":"85055","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85055","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BONE MARROW SMEAR INTERPRETATION","code_information":[{"code":"85097","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85097","type":"HCPCS"}],"standard_charges":[{"gross_charge":834.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHROMOGENIC SUBSTRATE ASSAY","code_information":[{"code":"85130","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85130","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR II PROTHROMBIN SPECIFIC","code_information":[{"code":"85210","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85210","type":"HCPCS"}],"standard_charges":[{"gross_charge":597.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR V ACG/PROACCELERIN LABILE FACTOR","code_information":[{"code":"85220","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85220","type":"HCPCS"}],"standard_charges":[{"gross_charge":496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR VII PROCONVERTIN STABLE FACTOR","code_information":[{"code":"85230","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85230","type":"HCPCS"}],"standard_charges":[{"gross_charge":629.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR VIII AHG 1 STAGE","code_information":[{"code":"85240","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85240","type":"HCPCS"}],"standard_charges":[{"gross_charge":710.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR VIII VW FACTOR RISTOCETIN COFACT","code_information":[{"code":"85245","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85245","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR VIII VW FACTOR ANTIGEN","code_information":[{"code":"85246","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85246","type":"HCPCS"}],"standard_charges":[{"gross_charge":562.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR VIII MULTIMETRIC ANALYSIS","code_information":[{"code":"85247","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85247","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR IX PTC/CHRISTMAS","code_information":[{"code":"85250","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85250","type":"HCPCS"}],"standard_charges":[{"gross_charge":631.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR X STUART-PROWER","code_information":[{"code":"85260","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85260","type":"HCPCS"}],"standard_charges":[{"gross_charge":496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR XI PTA","code_information":[{"code":"85270","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85270","type":"HCPCS"}],"standard_charges":[{"gross_charge":557.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR XII HAGEMAN","code_information":[{"code":"85280","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85280","type":"HCPCS"}],"standard_charges":[{"gross_charge":496.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING FACTOR XIII FIBRIN STABILIZING","code_information":[{"code":"85290","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85290","type":"HCPCS"}],"standard_charges":[{"gross_charge":633.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING INHIBITORS ANTITHROMBIN III ACTIVITY","code_information":[{"code":"85300","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85300","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING INHIBITRS ANTITHROMBN III ANTIGEN ASSAY","code_information":[{"code":"85301","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85301","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING INHIBITORS PROTEIN C ANTIGEN","code_information":[{"code":"85302","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85302","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING INHIBITORS PROTEIN C ACTIVITY","code_information":[{"code":"85303","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85303","type":"HCPCS"}],"standard_charges":[{"gross_charge":474.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING INHIBITORS PROTEIN S TOTAL","code_information":[{"code":"85305","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85305","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CLOTTING INHIBITORS PROTEIN S FREE","code_information":[{"code":"85306","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85306","type":"HCPCS"}],"standard_charges":[{"gross_charge":373.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACTIVATED PROTEIN C APC RESISTANCE ASSAY","code_information":[{"code":"85307","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85307","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FACTOR INHIBITOR TEST","code_information":[{"code":"85335","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COAGULATION TIME ACTIVATED","code_information":[{"code":"85347","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85347","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG EUGLOBULIN LYSIS","code_information":[{"code":"85360","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85360","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FIBRIN DGRADJ SPLT PRODUXS PARACOAGJ","code_information":[{"code":"85366","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85366","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE","code_information":[{"code":"85379","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85379","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FIBRIN DGRADJ PRODUCTS D-DIMER ULTRASENSITIVE","code_information":[{"code":"85380","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85380","type":"HCPCS"}],"standard_charges":[{"gross_charge":140.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FIBRINOGEN ACTIVITY","code_information":[{"code":"85384","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85384","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FIBRINOGEN ANTIGEN","code_information":[{"code":"85385","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85385","type":"HCPCS"}],"standard_charges":[{"gross_charge":234.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FIBRINOLYSINS/COAGULOPATHY SCREEN INTERP&REPOR","code_information":[{"code":"85390","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85390","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COAGJ/FBRNLYS ASSAY WHOLE BLOOD ADDITIVE PER DAY","code_information":[{"code":"85396","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85396","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COAGJ&FIBRINOLYSIS FUNCTIONAL ACTV NOS EA ANAL","code_information":[{"code":"85397","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85397","type":"HCPCS"}],"standard_charges":[{"gross_charge":464.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FBRNLYC FACTORS&INHIBITORS ALPHA-2 ANTIPLASMIN","code_information":[{"code":"85410","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85410","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FBRNLYC FACTORS&INHIBITORS PLSMNG ACTIVATOR","code_information":[{"code":"85415","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85415","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FBRNLYC FACTORS&INHIBITRS PLSMNG XCPT AGIC ASS","code_information":[{"code":"85420","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85420","type":"HCPCS"}],"standard_charges":[{"gross_charge":309.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FBRNLYC FACTORS&INHIBITORS PLSMNG AGIC ASSAY","code_information":[{"code":"85421","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85421","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEINZ BODIES DIRECT","code_information":[{"code":"85441","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85441","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEINZ BODIES INDUCED ACETYL PHENYLHYDRAZINE","code_information":[{"code":"85445","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85445","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HGB/RBCS FETAL FETOMATERNAL HEMRRG DIFRNTL LYSIS","code_information":[{"code":"85460","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85460","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HGB/RBCS FETAL FETOMATERNAL HEMRRG ROSETTE","code_information":[{"code":"85461","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85461","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPARIN ASSAY","code_information":[{"code":"85520","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85520","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG WBC ALKALINE PHOSPHATASE COUNT","code_information":[{"code":"85540","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85540","type":"HCPCS"}],"standard_charges":[{"gross_charge":243.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MURAMIDASE","code_information":[{"code":"85549","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85549","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OSMOTIC FRAGILITY RBC UNINCUBATED","code_information":[{"code":"85555","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85555","type":"HCPCS"}],"standard_charges":[{"gross_charge":426.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OSMOTIC FRAGILITY RBC INCUBATED","code_information":[{"code":"85557","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85557","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PLATELET AGGREGATION IN VITRO EACH AGENT","code_information":[{"code":"85576","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85576","type":"HCPCS"}],"standard_charges":[{"gross_charge":531.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PHOSPHOLIPID NEUTRALIZATION HEXAGONAL","code_information":[{"code":"85598","type":"CDM"},{"code":"0302","type":"RC"},{"code":"85598","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTHROMBIN TIME","code_information":[{"code":"85610","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PROTHROMBIN TIME SUBSTITUTION PLASMA FRCTJ EACH","code_information":[{"code":"85611","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85611","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG RUSSELL VIPER VENOM TIME DILUTED","code_information":[{"code":"85613","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG REPTILASE TEST","code_information":[{"code":"85635","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85635","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SEDIMENTATION RATE RBC AUTOMATED","code_information":[{"code":"85652","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85652","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SICKLING RBC REDUCTION","code_information":[{"code":"85660","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85660","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THROMBIN TIME PLASMA","code_information":[{"code":"85670","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85670","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THROMBOPLASTIN INHIBITION TISSUE","code_information":[{"code":"85705","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85705","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD","code_information":[{"code":"85730","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85730","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THROMBOPLASTIN TIME PRTL SUBSTIT PLASMA FRCTJ EA","code_information":[{"code":"85732","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85732","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VISCOSITY","code_information":[{"code":"85810","type":"CDM"},{"code":"0305","type":"RC"},{"code":"85810","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AGGLUTININS FEBRILE EACH ANTIGEN","code_information":[{"code":"86000","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86000","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALLERGEN SPECIFIC IGG QUAN/SEMIQUAN EA ALLERGEN","code_information":[{"code":"86001","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86001","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH","code_information":[{"code":"86003","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALLERGEN SPEC IGE QUAL MULTIALLERGEN SCREEN","code_information":[{"code":"86005","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86005","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ALLERGEN SPEC IGE RECOMBINANT/PURIFIED COMPNT EA","code_information":[{"code":"86008","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86008","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACTIN SMOOTH MUSCLE ANTIBODY EACH","code_information":[{"code":"86015","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86015","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY IDENTIFICATION LEUKOCYTE ANTIBODIES","code_information":[{"code":"86021","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86021","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY IDENTIFICATION PLATELET ANTIBODIES","code_information":[{"code":"86022","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY IDENTIFICATION PLATELET IMMUNOGL ASSAY","code_information":[{"code":"86023","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86023","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTINEUTROPHIL CYTOPLASMIC ANTB SCREEN EA ANTB","code_information":[{"code":"86036","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86036","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTINEUTROPHIL CYTOPLASMIC ANTB TITER EA ANTB","code_information":[{"code":"86037","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86037","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTINUCLEAR ANTIBODIES ANA","code_information":[{"code":"86038","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86038","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTINUCLEAR ANTIBODIES ANA TITER","code_information":[{"code":"86039","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86039","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACETYLCHOLINE RECEPTOR BINDING ANTIBODY","code_information":[{"code":"86041","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86041","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODY","code_information":[{"code":"86042","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86042","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY","code_information":[{"code":"86043","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86043","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AQUAPORIN-4 ANTIBODY CELL-BASED IMFLUOR ASSAY EA","code_information":[{"code":"86052","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86052","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AQUAPORIN-4 ANTIBODY FLOW CYTOMETRY EACH","code_information":[{"code":"86053","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86053","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTISTREPTOLYSIN O TITER","code_information":[{"code":"86060","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86060","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTISTREPTOLYSIN O SCREEN","code_information":[{"code":"86063","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86063","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG C-REACTIVE PROTEIN","code_information":[{"code":"86140","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86140","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG C-REACTIVE PROTEIN HIGH SENSITIVITY","code_information":[{"code":"86141","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86141","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BETA 2 GLYCOPROTEIN I ANTIBODY EACH","code_information":[{"code":"86146","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86146","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CARDIOLIPIN ANTIBODY EACH IG CLASS","code_information":[{"code":"86147","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTI-PHOSPHATIDYLSERINE ANTIBODY","code_information":[{"code":"86148","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86148","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COLD AGGLUTININ SCREEN","code_information":[{"code":"86156","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86156","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COLD AGGLUTININ TITER","code_information":[{"code":"86157","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86157","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPLEMENT ANTIGEN EACH COMPONENT","code_information":[{"code":"86160","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPLEMENT FUNCTIONAL ACTIVITY EACH COMPONENT","code_information":[{"code":"86161","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86161","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPLEMENT TOTAL HEMOLYTIC","code_information":[{"code":"86162","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86162","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYCLIC CITRULLINATED PEPTIDE ANTIBODY","code_information":[{"code":"86200","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86200","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DEOXYRIBONUCLEASE ANTIBODY","code_information":[{"code":"86215","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86215","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DNA ANTIBODY NATIVE/DOUBLE STRANDED","code_information":[{"code":"86225","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86225","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ENDOMYSIAL ANTIBODY EACH IMMUNOGLOBULIN CLASS","code_information":[{"code":"86231","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86231","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD","code_information":[{"code":"86235","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLUORESCENT NONNFCT AGT ANTB SCREEN EA ANTIBODY","code_information":[{"code":"86255","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLUORESCENT NONNFCT AGT ANTB TITER EA ANTIBODY","code_information":[{"code":"86256","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS","code_information":[{"code":"86258","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86258","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3","code_information":[{"code":"86300","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86300","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9","code_information":[{"code":"86301","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86301","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125","code_information":[{"code":"86304","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86304","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HUMAN EPIDIDYMIS PROTEIN 4 (HE4)","code_information":[{"code":"86305","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86305","type":"HCPCS"}],"standard_charges":[{"gross_charge":620.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HETEROPHILE ANTIBODIES SCREEN","code_information":[{"code":"86308","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86308","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE","code_information":[{"code":"86316","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86316","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOASSAY INFECTIOUS AGENT ANTIBODY QUAN NOS","code_information":[{"code":"86317","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":338.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IA INFECTIOUS AGT ANTIBODY QUAL/SEMIQ 1STEP METH","code_information":[{"code":"86318","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86318","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IA INFECTIOUS AGT ANTIBODY SARS-COV-2 COVID-19","code_information":[{"code":"86328","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86328","type":"HCPCS"}],"standard_charges":[{"gross_charge":131.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNODIFFUSION NOT ELSEWHERE SPECIFIED","code_information":[{"code":"86329","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86329","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNODIFFUSION GEL DIFFUSION QUAL EA AG/ANTBDY","code_information":[{"code":"86331","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86331","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNE COMPLEX ASSAY","code_information":[{"code":"86332","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86332","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOFIXJ ELECTROPHORESIS SERUM","code_information":[{"code":"86334","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86334","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS","code_information":[{"code":"86335","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86335","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG INHIBIN A","code_information":[{"code":"86336","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86336","type":"HCPCS"}],"standard_charges":[{"gross_charge":320.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG INSULIN ANTIBODIES","code_information":[{"code":"86337","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86337","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG INTRINSIC FACTOR ANTIBODIES","code_information":[{"code":"86340","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86340","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ISLET CELL ANTIBODY","code_information":[{"code":"86341","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86341","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEUKOCYTE HISTAMINE RELEASE TEST LHR","code_information":[{"code":"86343","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86343","type":"HCPCS"}],"standard_charges":[{"gross_charge":492.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CELLULAR FUNCTION ASSAY STIMUL&DETECT BIOMARKE","code_information":[{"code":"86352","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86352","type":"HCPCS"}],"standard_charges":[{"gross_charge":418.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LYMPHOCYTE TR MITOGEN/AG INDUCED BLASTOGENESIS","code_information":[{"code":"86353","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86353","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG B CELLS TOTAL COUNT","code_information":[{"code":"86355","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86355","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MONONUCLEAR CELL ANTIGEN QUANTITATIVE NOS EA","code_information":[{"code":"86356","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NATURAL KILLER CELLS TOTAL COUNT","code_information":[{"code":"86357","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86357","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG T CELLS TOTAL COUNT","code_information":[{"code":"86359","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86359","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG T CELLS ABSOLUTE CD4&CD8 COUNT RATIO","code_information":[{"code":"86360","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86360","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG T CELLS ABSOLUTE CD4 COUNT","code_information":[{"code":"86361","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86361","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOG-IGG1 ANTIBODY CELL-BASED IMFLUOR ASSAY EACH","code_information":[{"code":"86362","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86362","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOG-IGG1 ANTIBODY FLOW CYTOMETRY EACH","code_information":[{"code":"86363","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86363","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISSUE TRANSGLUTAMINASE EA IMMUNOGLOBULIN CLASS","code_information":[{"code":"86364","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86364","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MUSCLE-SPECIFIC KINASE ANTIBODY","code_information":[{"code":"86366","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86366","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MICROSOMAL ANTIBODIES EACH","code_information":[{"code":"86376","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86376","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MITOCHONDRIAL ANTIBODY EACH","code_information":[{"code":"86381","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86381","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NEUTRALIZATION TEST VIRAL","code_information":[{"code":"86382","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86382","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NITROBLUE TETRAZOLIUM DYE TEST NTD","code_information":[{"code":"86384","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86384","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PARTICLE AGGLUTINATION SCREEN EACH ANTIBODY","code_information":[{"code":"86403","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86403","type":"HCPCS"}],"standard_charges":[{"gross_charge":73.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG RHEUMATOID FACTOR QUALITATIVE","code_information":[{"code":"86430","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86430","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG RHEUMATOID FACTOR QUANTITATIVE","code_information":[{"code":"86431","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86431","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON","code_information":[{"code":"86480","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86480","type":"HCPCS"}],"standard_charges":[{"gross_charge":256.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP","code_information":[{"code":"86481","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86481","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SKIN TEST TUBERCULOSIS INTRADERMAL","code_information":[{"code":"86580","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86580","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG STRPTCS PNEUM ANTIBODY IGG SEROTYPES MLT IA QUAN","code_information":[{"code":"86581","type":"CDM"},{"code":"0300","type":"RC"},{"code":"86581","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL","code_information":[{"code":"86592","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86592","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SYPHILIS TEST QUANTITATIVE","code_information":[{"code":"86593","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86593","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VOLTAGE-GATED CALCIUM CHANNEL ANTIBODY EACH","code_information":[{"code":"86596","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86596","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ADENOVIRUS","code_information":[{"code":"86603","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86603","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ASPERGILLUS","code_information":[{"code":"86606","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86606","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BACTERIUM NOT ELSEWHERE SPECIFIED","code_information":[{"code":"86609","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86609","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BARTONELLA","code_information":[{"code":"86611","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86611","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BLASTOMYCES","code_information":[{"code":"86612","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86612","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BORDETELLA","code_information":[{"code":"86615","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86615","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BORRELIA BURGDORFERI CONFIRMATORY TST","code_information":[{"code":"86617","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86617","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BORRELIA BURGDORFERI LYME DISEASE","code_information":[{"code":"86618","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BORRELIA RELAPSING FEVER","code_information":[{"code":"86619","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86619","type":"HCPCS"}],"standard_charges":[{"gross_charge":329.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY BRUCELLA","code_information":[{"code":"86622","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86622","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CAMPYLOBACTER","code_information":[{"code":"86625","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86625","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CANDIDA","code_information":[{"code":"86628","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86628","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CHLAMYDIA","code_information":[{"code":"86631","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86631","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CHLAMYDIA IGM","code_information":[{"code":"86632","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86632","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY COCCIDIOIDES","code_information":[{"code":"86635","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY COXIELLA BURNETII Q FEVER","code_information":[{"code":"86638","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86638","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CRYPTOCOCCUS","code_information":[{"code":"86641","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86641","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CYTOMEGALOVIRUS CMV","code_information":[{"code":"86644","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86644","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY CYTOMEGALOVIRUS CMV IGM","code_information":[{"code":"86645","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86645","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY DIPHTHERIA","code_information":[{"code":"86648","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86648","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ENCEPHALITIS CALIFORNIA LA CROSSE","code_information":[{"code":"86651","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86651","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ENCEPHALITIS EASTERN EQUINE","code_information":[{"code":"86652","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86652","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ENCEPHALITIS ST. LOUIS","code_information":[{"code":"86653","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86653","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ENCEPHALITIS WESTRN EQUINE","code_information":[{"code":"86654","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86654","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ENTEROVIRUS","code_information":[{"code":"86658","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86658","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY EPSTEIN-BARR EB VIRUS EARLY ANTIGEN EA","code_information":[{"code":"86663","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86663","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA","code_information":[{"code":"86664","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86664","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA","code_information":[{"code":"86665","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86665","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY EHRLICHIA","code_information":[{"code":"86666","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86666","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY FRANCISELLA TULARENSIS","code_information":[{"code":"86668","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86668","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY FUNGUS NOT ELSEWHERE SPECIFIED","code_information":[{"code":"86671","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86671","type":"HCPCS"}],"standard_charges":[{"gross_charge":297.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY GIARDIA LAMBLIA","code_information":[{"code":"86674","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86674","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HELICOBACTER PYLORI","code_information":[{"code":"86677","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86677","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HELMINTH NOT ELSEWHERE SPECIFIED","code_information":[{"code":"86682","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86682","type":"HCPCS"}],"standard_charges":[{"gross_charge":277.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HAEMOPHILUS INFLUENZA","code_information":[{"code":"86684","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86684","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HTLV-I","code_information":[{"code":"86687","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86687","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HEP DELTA AGENT","code_information":[{"code":"86692","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86692","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HERPES SMPLX NON-SPECIFIC TYPE TEST","code_information":[{"code":"86694","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86694","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HERPES SMPLX TYPE 1","code_information":[{"code":"86695","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86695","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HERPES SMPLX TYPE 2","code_information":[{"code":"86696","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86696","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HISTOPLASMA","code_information":[{"code":"86698","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86698","type":"HCPCS"}],"standard_charges":[{"gross_charge":72.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HIV-1","code_information":[{"code":"86701","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86701","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HIV-2","code_information":[{"code":"86702","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86702","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HIV-1&HIV-2 SINGLE RESULT","code_information":[{"code":"86703","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86703","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS B CORE ANTIBODY HBCAB TOTAL","code_information":[{"code":"86704","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86704","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS B CORE ANTIBODY HBCAB IGM ANTIBODY","code_information":[{"code":"86705","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86705","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS B SURF ANTIBODY HBSAB","code_information":[{"code":"86706","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86706","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS BE ANTIBODY HBEAB","code_information":[{"code":"86707","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86707","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS A ANTIBODY HAAB","code_information":[{"code":"86708","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86708","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS ANTIBODY HAAB IGM ANTIBODY","code_information":[{"code":"86709","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86709","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY INFLUENZA VIRUS","code_information":[{"code":"86710","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86710","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY JOHN CUNNINGHAM VIRUS","code_information":[{"code":"86711","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86711","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY LEGIONELLA","code_information":[{"code":"86713","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86713","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY LEISHMANIA","code_information":[{"code":"86717","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86717","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY LEPTOSPIRA","code_information":[{"code":"86720","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86720","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY LISTERIA MONOCYTOGENES","code_information":[{"code":"86723","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86723","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY LYMPHOCYTIC CHORIOMENINGITIS","code_information":[{"code":"86727","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86727","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY MUMPS","code_information":[{"code":"86735","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86735","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY MYCOPLSM","code_information":[{"code":"86738","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86738","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY NEISSERIA MENINGITIDIS","code_information":[{"code":"86741","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86741","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY PARVOVIRUS","code_information":[{"code":"86747","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86747","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY PLASMODIUM MALARIA","code_information":[{"code":"86750","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86750","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY PROTOZOA NES","code_information":[{"code":"86753","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86753","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY RESPIRATORY SYNCTIAL VIRUS","code_information":[{"code":"86756","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86756","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY RICKETTSIA","code_information":[{"code":"86757","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86757","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY RUBELLA","code_information":[{"code":"86762","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86762","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY RUBEOLA","code_information":[{"code":"86765","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86765","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY SALMONELLA","code_information":[{"code":"86768","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86768","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTB SEVERE AQT RESPIR SYND SARS-COV-2 COVID-19","code_information":[{"code":"86769","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86769","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY TETANUS","code_information":[{"code":"86774","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86774","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY TOXOPLASMA","code_information":[{"code":"86777","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86777","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY TOXOPLASMA IGM","code_information":[{"code":"86778","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86778","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY TREPONEMA PALLIDUM","code_information":[{"code":"86780","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86780","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY TRICHINELLA","code_information":[{"code":"86784","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86784","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY VARICELLA-ZOSTER","code_information":[{"code":"86787","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":104.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY WEST NILE VIRUS IGM","code_information":[{"code":"86788","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86788","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY WEST NILE VIRUS","code_information":[{"code":"86789","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86789","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED","code_information":[{"code":"86790","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY YERSINIA","code_information":[{"code":"86793","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86793","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ZIKA VIRUS IGM ANTIBODY","code_information":[{"code":"86794","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86794","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THYROGLOBULIN ANTIBODY","code_information":[{"code":"86800","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86800","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS C ANTIBODY","code_information":[{"code":"86803","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86803","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LYMPHOCYTOTOXICITY ASSAY VIS CROSSMATCH TITRATJ","code_information":[{"code":"86805","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86805","type":"HCPCS"}],"standard_charges":[{"gross_charge":589.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA TYPING A/B/C SINGLE ANTIGEN","code_information":[{"code":"86812","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86812","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HLA CROSSMATCH NONCYTOTOXIC 1ST SERUM/DILUTION","code_information":[{"code":"86825","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86825","type":"HCPCS"}],"standard_charges":[{"gross_charge":339.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS I & CLASS II ANTIGENS QUAL","code_information":[{"code":"86828","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86828","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS I PHENOTYPE PANEL QUALITATIVE","code_information":[{"code":"86830","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86830","type":"HCPCS"}],"standard_charges":[{"gross_charge":308.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS II PHENOTYPE PANEL QUAL","code_information":[{"code":"86831","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86831","type":"HCPCS"}],"standard_charges":[{"gross_charge":274.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS I HIGH DEFINITION PANEL QUAL","code_information":[{"code":"86832","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86832","type":"HCPCS"}],"standard_charges":[{"gross_charge":773.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS II HIGH DEFINITION PANEL QUAL","code_information":[{"code":"86833","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86833","type":"HCPCS"}],"standard_charges":[{"gross_charge":771.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS I SEMIQUANTITATIVE PANEL","code_information":[{"code":"86834","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86834","type":"HCPCS"}],"standard_charges":[{"gross_charge":1326.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY HLA CLASS II SEMIQUANTITATIVE PANEL","code_information":[{"code":"86835","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86835","type":"HCPCS"}],"standard_charges":[{"gross_charge":1203.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE","code_information":[{"code":"86850","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ELUTION RBC EACH ELUTION","code_information":[{"code":"86860","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86860","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIBODY ID RBC ANTIBODIES EA PANEL EA SERUM TQ","code_information":[{"code":"86870","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":375.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIHUMAN GLOBULIN DIRECT EACH ANTISERUM","code_information":[{"code":"86880","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86880","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIHUMAN GLOBULIN INDIR QUAL EA REAGENT CELL","code_information":[{"code":"86885","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86885","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ANTIHUMAN GLOBULIN INDIRECT EACH ANTIBODY TITER","code_information":[{"code":"86886","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86886","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG AUTOL BLD/COMPONENT COLLJ STORAGE SALVAGE","code_information":[{"code":"86891","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86891","type":"HCPCS"}],"standard_charges":[{"gross_charge":2544.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD TYPING SEROLOGIC ABO","code_information":[{"code":"86900","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86900","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD TYPING SEROLOGIC RH (D)","code_information":[{"code":"86901","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86901","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EACH","code_information":[{"code":"86902","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":312.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD TYPING ANTIGEN SCREEN PATIENT SERUM/UNIT","code_information":[{"code":"86904","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86904","type":"HCPCS"}],"standard_charges":[{"gross_charge":123.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD TYPING RBC ANTIGENS OTH/THN ABO/RH D EACH","code_information":[{"code":"86905","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG BLOOD TYPING SEROLOGIC RH PHENOTYPING COMPLETE","code_information":[{"code":"86906","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86906","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPATIBILITY EACH UNIT IMMEDIATE SPIN TECHNIQUE","code_information":[{"code":"86920","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86920","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPATIBILITY EACH UNIT INCUBATION","code_information":[{"code":"86921","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86921","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPATIBILITY EACH UNIT ANTIGLOBULIN","code_information":[{"code":"86922","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86922","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COMPATIBILITY EACH UNIT ELECTRONIC","code_information":[{"code":"86923","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86923","type":"HCPCS"}],"standard_charges":[{"gross_charge":224.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FRESH FROZEN PLASMA THAWING EACH UNIT","code_information":[{"code":"86927","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86927","type":"HCPCS"}],"standard_charges":[{"gross_charge":566.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOLYSINS&AGGLUTININS AUTO SCREEN EACH","code_information":[{"code":"86940","type":"CDM"},{"code":"0300","type":"RC"},{"code":"86940","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEMOLYSINS&AGGLUTININS INCUBATED","code_information":[{"code":"86941","type":"CDM"},{"code":"0300","type":"RC"},{"code":"86941","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IRRADIATION BLOOD PRODUCT EACH UNIT","code_information":[{"code":"86945","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86945","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG POOLING PLATELETS/OTHER BLOOD PRODUCTS","code_information":[{"code":"86965","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86965","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PRETX RBC ANTIBODY INCUBAT W/CHEM AGNTS/DRUGS EA","code_information":[{"code":"86970","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86970","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PRETX RBC ANTIBODY INCUBAT W/ENZYMES EACH","code_information":[{"code":"86971","type":"CDM"},{"code":"0300","type":"RC"},{"code":"86971","type":"HCPCS"}],"standard_charges":[{"gross_charge":312.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PRETX RBC ANTIBODY INCUBAT W/DENSITY GRAD SEP","code_information":[{"code":"86972","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86972","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PRETX SERUM RBC ANTIBODY IDENTIFICATION DILUTION","code_information":[{"code":"86976","type":"CDM"},{"code":"0300","type":"RC"},{"code":"86976","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PRETX SERUM RBC ANTIBODY ID DIFFIAL EACH ABSRPJ","code_information":[{"code":"86978","type":"CDM"},{"code":"0302","type":"RC"},{"code":"86978","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CONCENTRATION INFECTIOUS AGENTS","code_information":[{"code":"87015","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87015","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES","code_information":[{"code":"87040","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87040","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL","code_information":[{"code":"87045","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87045","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA","code_information":[{"code":"87046","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87046","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL","code_information":[{"code":"87070","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT QUAN AEROBIC ISOL XCPT UR BLOOD/STOOL","code_information":[{"code":"87071","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87071","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT QUAN ANAERC ISOL XCPT UR BLOOD/STOOL","code_information":[{"code":"87073","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87073","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID","code_information":[{"code":"87075","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87075","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL","code_information":[{"code":"87076","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87076","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL","code_information":[{"code":"87077","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87077","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ","code_information":[{"code":"87081","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":487.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE","code_information":[{"code":"87086","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87086","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE","code_information":[{"code":"87088","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87088","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL","code_information":[{"code":"87101","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87101","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD","code_information":[{"code":"87102","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87102","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD","code_information":[{"code":"87103","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87103","type":"HCPCS"}],"standard_charges":[{"gross_charge":73.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE FUNGI DEFINITIVE ID EACH ORGANISM YEAST","code_information":[{"code":"87106","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87106","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE FUNGI DEFINITIVE ID EACH ORGANISM MOLD","code_information":[{"code":"87107","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87107","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE MYCOPLASMA ANY SOURCE","code_information":[{"code":"87109","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87109","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE CHLAMYDIA ANY SOURCE","code_information":[{"code":"87110","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87110","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE TUBERCLE/OTH ACID-FAST BACILLI ANY ISOL","code_information":[{"code":"87116","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87116","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE MYCOBACTERIAL DEFINITIVE ID EA ISOL","code_information":[{"code":"87118","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87118","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE TYPING IMMUNOFLUORESCENT EACH ANTISERUM","code_information":[{"code":"87140","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87140","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE TYPING IMMUNOLOGIC OTH/THN IMMUNOFLUORES","code_information":[{"code":"87147","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87147","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM","code_information":[{"code":"87150","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87150","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTYP NUCLEIC ACID SEQUENCING METH EA ISOLATE","code_information":[{"code":"87153","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87153","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CULTURE TYPING ID BLD PTHGN&RESIST TYPING 6+TRGT","code_information":[{"code":"87154","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87154","type":"HCPCS"}],"standard_charges":[{"gross_charge":677.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MACROSCOPIC EXAMINATION ARTHROPOD","code_information":[{"code":"87168","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87168","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MACROSCOPIC EXAMINATION PARASITE","code_information":[{"code":"87169","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87169","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PINWORM EXAMINATION","code_information":[{"code":"87172","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87172","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HOMOGENIZATION TISSUE CULTURE","code_information":[{"code":"87176","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87176","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID","code_information":[{"code":"87177","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87177","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SUSCEPTBILTY STDY ANTIMICRBIAL AGNT AGAR DILUTJ","code_information":[{"code":"87181","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87181","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD","code_information":[{"code":"87184","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87184","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SUSCEPTIBILITY STUDY ANTIMICROBIAL ENZYME DETCJ","code_information":[{"code":"87185","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87185","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SUSCEPTIBLTY STDY ANTIMICRBIAL MICRO/AGAR DILUTJ","code_information":[{"code":"87186","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SC STD ANTMCRB AGT MACROBROTH DIL METH EA AGT","code_information":[{"code":"87188","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87188","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SERUM BACTERICIDAL TITER","code_information":[{"code":"87197","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87197","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL","code_information":[{"code":"87205","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87205","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMR PRIM SRC FLUORESCENT&/AFS BCT FNGI PARASIT","code_information":[{"code":"87206","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87206","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMR PRIM SRC SPEC STAIN BODIES/PARASITS","code_information":[{"code":"87207","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87207","type":"HCPCS"}],"standard_charges":[{"gross_charge":140.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS","code_information":[{"code":"87209","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87209","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SMR PRIM SRC WET MOUNT NFCT AGT","code_information":[{"code":"87210","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87210","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISS KOH SLIDE SAMPS SKN/HR/NLS FNGI/ECTOPARASIT","code_information":[{"code":"87220","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87220","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TOXIN/ANTITOXIN ASSAY TISSUE CULTURE","code_information":[{"code":"87230","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87230","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT","code_information":[{"code":"87252","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87252","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE","code_information":[{"code":"87253","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87253","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VIRUS CENTRIFUGE ENHNCD ID IMFLUOR STAIN EA","code_information":[{"code":"87254","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87254","type":"HCPCS"}],"standard_charges":[{"gross_charge":131.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC","code_information":[{"code":"87255","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87255","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI ADENOVIRUS","code_information":[{"code":"87260","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87260","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI GIARDIA","code_information":[{"code":"87269","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87269","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI CHLAMYDIA TRACHOMATIS","code_information":[{"code":"87270","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87270","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI CRYPTOSPORIDIUM","code_information":[{"code":"87272","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87272","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI HERPES SMPLX VIRUS TYPE 2","code_information":[{"code":"87273","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87273","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI HERPES SMPLX VIRUS TYPE 1","code_information":[{"code":"87274","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87274","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI INFLUENZA B VIRUS","code_information":[{"code":"87275","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87275","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI INFFLUENZA A VIRUS","code_information":[{"code":"87276","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87276","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI LEGIONELLA PNEUMOPHILA","code_information":[{"code":"87278","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87278","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI PARAINFLUENZA VIRUS EACH TYPE","code_information":[{"code":"87279","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87279","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI RESPIRATORY SYNCTIAL VIRUS","code_information":[{"code":"87280","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87280","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI PNEUMOCUSTIS CARINII","code_information":[{"code":"87281","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87281","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI TREPONEMA PALLIDUM","code_information":[{"code":"87285","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87285","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI VARICELLA ZOSTER VIRUS","code_information":[{"code":"87290","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87290","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADI NOT OTHERWISE SPECIFIED EACH ORGANISM","code_information":[{"code":"87299","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87299","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA ADENOVIRUS ENTERIC TYP 40/41","code_information":[{"code":"87301","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87301","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA ASPERGILLUS","code_information":[{"code":"87305","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87305","type":"HCPCS"}],"standard_charges":[{"gross_charge":624.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA CLOSTRIDIUM DIFFICILE TOXIN","code_information":[{"code":"87324","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87324","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA CRYPTOCOCCUS NEOFORMANS","code_information":[{"code":"87327","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87327","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA CRYPTOSPORIDIUM","code_information":[{"code":"87328","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87328","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA GIARDIA","code_information":[{"code":"87329","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87329","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA ENTAMOEBA HISTOLYTICA GRP","code_information":[{"code":"87337","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87337","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HPYLORI STOOL","code_information":[{"code":"87338","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87338","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HPYLORI","code_information":[{"code":"87339","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87339","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HEPATITIS B SURFACE ANTIGEN","code_information":[{"code":"87340","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87340","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION","code_information":[{"code":"87341","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87341","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HEPATITIS BE ANTIGEN","code_information":[{"code":"87350","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87350","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HEPATITIS DELTA ANTIGEN","code_information":[{"code":"87380","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87380","type":"HCPCS"}],"standard_charges":[{"gross_charge":940.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HISTOPLASM CAPSULATUM","code_information":[{"code":"87385","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87385","type":"HCPCS"}],"standard_charges":[{"gross_charge":509.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE","code_information":[{"code":"87389","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87389","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CAR T THERAPY AUTOL CAR T CELL ADMINISTRATION","code_information":[{"code":"8740000000","type":"CDM"},{"code":"0874","type":"RC"},{"code":"38228","type":"HCPCS"}],"standard_charges":[{"gross_charge":1270.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA RESPIRATORY SYNCTIAL VIRUS","code_information":[{"code":"87420","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87420","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA ROTAVIRUS","code_information":[{"code":"87425","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87425","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA SHIGA-LIKE TOXIN","code_information":[{"code":"87427","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87427","type":"HCPCS"}],"standard_charges":[{"gross_charge":73.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA STREPTOCOCCUS GROUP A","code_information":[{"code":"87430","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87430","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAAD IA NOT OTHERWISE SPECIFIED EACH ORGANISM","code_information":[{"code":"87449","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG HEPATITIS B SURFACE ANTIGEN QUANTITATIVE","code_information":[{"code":"87467","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87467","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA ANAPLASMA PHAGOCYTOPHILUM AMPLIFED PRB TQ","code_information":[{"code":"87468","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87468","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA BABESIA MICROTI AMPLIFIED PROBE TECHNIQUE","code_information":[{"code":"87469","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87469","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA BARTONELLA AMPLIFIED PROBE TECHNIQUE","code_information":[{"code":"87471","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87471","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA BORRELIA BURGDORFERI AMPLIFIED PROBE TQ","code_information":[{"code":"87476","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87476","type":"HCPCS"}],"standard_charges":[{"gross_charge":341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA BORRELIA MIYAMOTOI AMPLIFIED PRB TECHNIQUE","code_information":[{"code":"87478","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87478","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA CANDIDA SPECIES DIRECT PROBE TQ","code_information":[{"code":"87480","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87480","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA CANDIDA SPECIES AMPLIFIED PROBE TQ","code_information":[{"code":"87481","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87481","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25","code_information":[{"code":"87483","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87483","type":"HCPCS"}],"standard_charges":[{"gross_charge":1548.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA EHRLICHIA CHAFFEENSIS AMPLIFIED PROBE TQ","code_information":[{"code":"87484","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87484","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ","code_information":[{"code":"87486","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87486","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ","code_information":[{"code":"87491","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87491","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE","code_information":[{"code":"87493","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87493","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA CYTOMEGALOVIRUS AMPLIFIED PROBE TQ","code_information":[{"code":"87496","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87496","type":"HCPCS"}],"standard_charges":[{"gross_charge":917.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA CYTOMEGALOVIRUS QUANTIFICATION","code_information":[{"code":"87497","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87497","type":"HCPCS"}],"standard_charges":[{"gross_charge":1066.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA ENTEROVIRUS AMPLIF PROBE & REVRSE TRNSCRIP","code_information":[{"code":"87498","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87498","type":"HCPCS"}],"standard_charges":[{"gross_charge":726.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES","code_information":[{"code":"87502","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87502","type":"HCPCS"}],"standard_charges":[{"gross_charge":336.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 6-11","code_information":[{"code":"87506","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87506","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25","code_information":[{"code":"87507","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87507","type":"HCPCS"}],"standard_charges":[{"gross_charge":1305.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA GARDNERELLA VAGINALIS DIRECT PROBE TQ","code_information":[{"code":"87510","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87510","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA GARDNERELLA VAGINALIS AMPLIFIED PROBE TQ","code_information":[{"code":"87511","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87511","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA H PYLORI CLARITHROMYCIN RESIST AMP PRB TQ","code_information":[{"code":"87513","type":"CDM"},{"code":"0300","type":"RC"},{"code":"87513","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HEPATITIS B VIRUS QUANTIFICATION","code_information":[{"code":"87517","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87517","type":"HCPCS"}],"standard_charges":[{"gross_charge":1232.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HEPATITIS C AMPLIFIED PROBE&REVRSE TRANSCR","code_information":[{"code":"87521","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87521","type":"HCPCS"}],"standard_charges":[{"gross_charge":952.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION","code_information":[{"code":"87522","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87522","type":"HCPCS"}],"standard_charges":[{"gross_charge":608.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ","code_information":[{"code":"87529","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87529","type":"HCPCS"}],"standard_charges":[{"gross_charge":348.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HERPES SOMPLX VIRUS QUANTIFICATION","code_information":[{"code":"87530","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87530","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HERPES VIRUS-6 AMPLIFIED PROBE TQ","code_information":[{"code":"87532","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87532","type":"HCPCS"}],"standard_charges":[{"gross_charge":988.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HERPES VIRUS-6 QUANTIFICATION","code_information":[{"code":"87533","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87533","type":"HCPCS"}],"standard_charges":[{"gross_charge":287.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HIV-1 AMPLIFIED PROBE & REVERSE TRANSCRPJ","code_information":[{"code":"87535","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87535","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION","code_information":[{"code":"87536","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87536","type":"HCPCS"}],"standard_charges":[{"gross_charge":726.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HIV-2 AMPLIFIED PROBE & REVERSE TRANSCRIPJ","code_information":[{"code":"87538","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87538","type":"HCPCS"}],"standard_charges":[{"gross_charge":1088.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HIV-2 QUANT & REVERSE TRANSCRIPTION","code_information":[{"code":"87539","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87539","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA LEGIONELLA PNEUMOPHILA AMPLIFIED PROBE TQ","code_information":[{"code":"87541","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87541","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA MYCOBACTERIA SPECIES AMPLIFIED PROBE TQ","code_information":[{"code":"87551","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87551","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA MYCOBACTERIA TUBERCULOSIS AMP PRB","code_information":[{"code":"87556","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87556","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA MYCOPLASMA GENITALIUM AMPLIFIED PROBE TECH","code_information":[{"code":"87563","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87563","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA MTB RIFAMPIN RESISTANCE AMP PRB TQ","code_information":[{"code":"87564","type":"CDM"},{"code":"0300","type":"RC"},{"code":"87564","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ","code_information":[{"code":"87581","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87581","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA NEISSERIA GONORRHOEAE DIRECT PROBE TQ","code_information":[{"code":"87590","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87590","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ","code_information":[{"code":"87591","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87591","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA ORTHOPOXVIRUS AMPLIFIED PROBE TECHNIQUE EA","code_information":[{"code":"87593","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87593","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ","code_information":[{"code":"87594","type":"CDM"},{"code":"0300","type":"RC"},{"code":"87594","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HUMAN PAPILLOMAVIRUS LOW-RISK TYPES","code_information":[{"code":"87623","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87623","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HUMAN PAPILLOMAVIRUS HI-RSK TYP POOLD RSLT","code_information":[{"code":"87624","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87624","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HUMAN PAPILLOMAVIRUS TYPES 16 & 18 ONLY","code_information":[{"code":"87625","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87625","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA HPV SEP RPRT HI-RSK TYP&HI-RSK POOLD RSLTS","code_information":[{"code":"87626","type":"CDM"},{"code":"0300","type":"RC"},{"code":"87626","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA RESPIRATRY PROBE & REV TRNSCR 3-5 TARGETS","code_information":[{"code":"87631","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87631","type":"HCPCS"}],"standard_charges":[{"gross_charge":652.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA RESPIRATRY PROBE & REV TRNSCR 6-11 TARGETS","code_information":[{"code":"87632","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87632","type":"HCPCS"}],"standard_charges":[{"gross_charge":1026.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET","code_information":[{"code":"87633","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87633","type":"HCPCS"}],"standard_charges":[{"gross_charge":1359.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE","code_information":[{"code":"87634","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87634","type":"HCPCS"}],"standard_charges":[{"gross_charge":366.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ","code_information":[{"code":"87635","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87635","type":"HCPCS"}],"standard_charges":[{"gross_charge":229.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA SARSCOV2& INF A&B MULT AMPLIFIED PROBE TQ","code_information":[{"code":"87636","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87636","type":"HCPCS"}],"standard_charges":[{"gross_charge":652.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE TQ","code_information":[{"code":"87637","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87637","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA S AUREUS AMPLIFIED PROBE TQ","code_information":[{"code":"87640","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87640","type":"HCPCS"}],"standard_charges":[{"gross_charge":208.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA S AUREUS METHICILLIN RESIST AMP PROBE TQ","code_information":[{"code":"87641","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87641","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TQ","code_information":[{"code":"87651","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87651","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ","code_information":[{"code":"87653","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87653","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ","code_information":[{"code":"87660","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87660","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH","code_information":[{"code":"87661","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87661","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA DNA/RNA ZIKA VIRUS AMPLIFIED PROBE TQ","code_information":[{"code":"87662","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87662","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM","code_information":[{"code":"87798","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA NOS QUANTIFICATION EACH ORGANISM","code_information":[{"code":"87799","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87799","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ","code_information":[{"code":"87801","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87801","type":"HCPCS"}],"standard_charges":[{"gross_charge":871.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADIADOO INFLUENZA","code_information":[{"code":"87804","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87804","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADIADOO RESPIRATORY SYNCTIAL VIRUS","code_information":[{"code":"87807","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87807","type":"HCPCS"}],"standard_charges":[{"gross_charge":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADIADOO TRICHOMONAS VAGINALIS","code_information":[{"code":"87808","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87808","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADIADOO STREPTOCOCCUS GROUP A","code_information":[{"code":"87880","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87880","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IAADIADOO NOT OTHERWISE SPECIFIED","code_information":[{"code":"87899","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87899","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT AGT DRUG SUSCEPT PHENOTYPE PREDICTION","code_information":[{"code":"87900","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87900","type":"HCPCS"}],"standard_charges":[{"gross_charge":840.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT AGT GNOTYP ALYS NUCLE ACD HIV1 REV TRNSCRPT","code_information":[{"code":"87901","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87901","type":"HCPCS"}],"standard_charges":[{"gross_charge":682.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT AGENT GENOTYPE ALYS NUCLEIC ACD HEP C VIRUS","code_information":[{"code":"87902","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87902","type":"HCPCS"}],"standard_charges":[{"gross_charge":682.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT PHEXYP RESIST TISS CUL HIV FIRST 1-10 DRUGS","code_information":[{"code":"87903","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87903","type":"HCPCS"}],"standard_charges":[{"gross_charge":2345.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT PHEXYP RESIST TISS CUL HIV EA ADDL DRUG","code_information":[{"code":"87904","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87904","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT AGT GNOTYP ALYS NUCLE ACD HIV1 OTHER REGION","code_information":[{"code":"87906","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87906","type":"HCPCS"}],"standard_charges":[{"gross_charge":387.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT AGT GENOTYPE ALYS NUCLEIC ACID CMV","code_information":[{"code":"87910","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87910","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NFCT AGENT GENOTYPE ALYS NUCLEIC ACD HEP B VIRUS","code_information":[{"code":"87912","type":"CDM"},{"code":"0306","type":"RC"},{"code":"87912","type":"HCPCS"}],"standard_charges":[{"gross_charge":761.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NECROPSY GROSS EXAM STILLBORN/NEWBORN W/BRAIN","code_information":[{"code":"88014","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88014","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NECROPSY GROSS EXAM MACERATED STILLBORN","code_information":[{"code":"88016","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88016","type":"HCPCS"}],"standard_charges":[{"gross_charge":544.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NECROPSY LIMITD GROSS&/MCRSCP SINGLE ORGAN","code_information":[{"code":"88037","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88037","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ","code_information":[{"code":"88104","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88104","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ","code_information":[{"code":"88106","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88106","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP CONCENTRATION SMEARS & INTERPRETATION","code_information":[{"code":"88108","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88108","type":"HCPCS"}],"standard_charges":[{"gross_charge":131.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V","code_information":[{"code":"88112","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88112","type":"HCPCS"}],"standard_charges":[{"gross_charge":206.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL","code_information":[{"code":"88120","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88120","type":"HCPCS"}],"standard_charges":[{"gross_charge":759.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA","code_information":[{"code":"88121","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88121","type":"HCPCS"}],"standard_charges":[{"gross_charge":935.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN","code_information":[{"code":"88142","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88142","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP C/V FLU AUTO THIN MNL SCR&RESCR PHYS","code_information":[{"code":"88143","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88143","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP SMRS C/V SCR AUTO SYS MNL RESCR PHYS","code_information":[{"code":"88148","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88148","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ","code_information":[{"code":"88161","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88161","type":"HCPCS"}],"standard_charges":[{"gross_charge":440.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES","code_information":[{"code":"88162","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88162","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP SLIDES CERV/VAG MNL SCRN PHYSICIAN SUPV","code_information":[{"code":"88164","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88164","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST","code_information":[{"code":"88172","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88172","type":"HCPCS"}],"standard_charges":[{"gross_charge":461.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP EVAL FINE NEEDLE ASPIRATE INTERP & REPORT","code_information":[{"code":"88173","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88173","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS","code_information":[{"code":"88174","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88174","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS","code_information":[{"code":"88175","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88175","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD EA EVAL","code_information":[{"code":"88177","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88177","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLOW CYTOMETRY CELL CYCLE/DNA ANALYSIS","code_information":[{"code":"88182","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88182","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLOW CYTOMETRY CELL SURF MARKER TECHL ONLY 1ST","code_information":[{"code":"88184","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":191.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FLOW CYTOMETRY CELL SURF MARKER TECHL ONLY EA","code_information":[{"code":"88185","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":191.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UNLISTED CYTOPATHOLOGY PROCEDURE","code_information":[{"code":"88199","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88199","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISS CUL NON-NEO DISORDERS LYMPHOCYTE","code_information":[{"code":"88230","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88230","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX","code_information":[{"code":"88233","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88233","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS","code_information":[{"code":"88235","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88235","type":"HCPCS"}],"standard_charges":[{"gross_charge":412.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISS CUL NEO DISORDERS BONE MARROW BLOOD CELLS","code_information":[{"code":"88237","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88237","type":"HCPCS"}],"standard_charges":[{"gross_charge":284.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG TISS CUL NEO DISORDERS SOLID TUMOR","code_information":[{"code":"88239","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88239","type":"HCPCS"}],"standard_charges":[{"gross_charge":690.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CRYOPRSRV FRZING&STORAGE CELLS EA CELL LINE","code_information":[{"code":"88240","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88240","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG THAWING&EXPANSION FROZEN CELLS EACH ALIQUOT","code_information":[{"code":"88241","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88241","type":"HCPCS"}],"standard_charges":[{"gross_charge":158.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM BREAKAGE SYNDS SCORE 100 CLL","code_information":[{"code":"88249","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88249","type":"HCPCS"}],"standard_charges":[{"gross_charge":542.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM COUNT 5 CELL 1KARYOTYPE BANDING","code_information":[{"code":"88261","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88261","type":"HCPCS"}],"standard_charges":[{"gross_charge":795.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM COUNT 15-20 CLL 2KARYOTYP BANDING","code_information":[{"code":"88262","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":633.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM COUNT 45 CELL MOSAICISM 2KARYOTYPE","code_information":[{"code":"88263","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88263","type":"HCPCS"}],"standard_charges":[{"gross_charge":714.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM ANALYZE 20-25 CELLS","code_information":[{"code":"88264","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88264","type":"HCPCS"}],"standard_charges":[{"gross_charge":287.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM ALYS AMNIOTIC/VILLUS 15 CELL 1KARYOTYPE","code_information":[{"code":"88267","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88267","type":"HCPCS"}],"standard_charges":[{"gross_charge":840.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP","code_information":[{"code":"88269","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88269","type":"HCPCS"}],"standard_charges":[{"gross_charge":811.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR CYTOGENETICS DNA PROBE EACH","code_information":[{"code":"88271","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR CYTOGENETICS CHRMOML ISH 10-30 CLL","code_information":[{"code":"88273","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88273","type":"HCPCS"}],"standard_charges":[{"gross_charge":864.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLECULAR CYTOGENETICS INTERPHASE ISH 25-99 CLL","code_information":[{"code":"88274","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88274","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL","code_information":[{"code":"88275","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":206.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM ANALYSIS ADDL KARYOTYP EACH STUDY","code_information":[{"code":"88280","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88280","type":"HCPCS"}],"standard_charges":[{"gross_charge":287.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CHRMSM ANALYSIS ADDL CELLS COUNTED EACH STUDY","code_information":[{"code":"88285","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88285","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY","code_information":[{"code":"88300","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88300","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM","code_information":[{"code":"88302","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88302","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM","code_information":[{"code":"88304","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88304","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM","code_information":[{"code":"88305","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":206.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM","code_information":[{"code":"88307","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88307","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM","code_information":[{"code":"88309","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88309","type":"HCPCS"}],"standard_charges":[{"gross_charge":2141.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG DECALCIFICATION PROCEDURE","code_information":[{"code":"88311","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88311","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SPECIAL STAIN GROUP 1 MICROORGANISMS I&R","code_information":[{"code":"88312","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88312","type":"HCPCS"}],"standard_charges":[{"gross_charge":206.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SPCL STN 2 I&R EXCPT MICROORG/ENZYME/IMCYT","code_information":[{"code":"88313","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SPECIAL STAIN I&R HISTOCHEMICAL W/FROZEN TISSU","code_information":[{"code":"88314","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SPECIAL STAIN I&R GROUP III ENZYME CONSITUENTS","code_information":[{"code":"88319","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":1711.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CONSLTJ&REPRT REFERRED MATRL REQUIRING PREPJ SLD","code_information":[{"code":"88323","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88323","type":"HCPCS"}],"standard_charges":[{"gross_charge":268.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CONSLTJ COMPRE RVW RECORD REPRT REFERRED MATRL","code_information":[{"code":"88325","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88325","type":"HCPCS"}],"standard_charges":[{"gross_charge":940.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PATHOLOGY CONSULTATION DURING SURGERY","code_information":[{"code":"88329","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88329","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1ST SPEC","code_information":[{"code":"88331","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88331","type":"HCPCS"}],"standard_charges":[{"gross_charge":1006.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PATH CONSLTJ SURG EA ADDL BLK FROZEN SECTION","code_information":[{"code":"88332","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88332","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PATH CONSLTJ SURG CYTOLOGIC EXAM INITIAL SITE","code_information":[{"code":"88333","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88333","type":"HCPCS"}],"standard_charges":[{"gross_charge":1606.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PATH CONSLTJ SURG CYTOLOGIC EXAM EACH ADDL SITE","code_information":[{"code":"88334","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88334","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMHCHEM/IMCYTCHM EA ADDL SINGLE ANTB STAIN PX","code_information":[{"code":"88341","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMHCHEM/IMCYTCHM 1ST SINGLE ANTB STAIN PROCEDURE","code_information":[{"code":"88342","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":656.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMHCHEM/IMCYTCHM EA MULTIPLEX ANTIBODY STAIN PX","code_information":[{"code":"88344","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88344","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOFLUORESCENCE PER SPEC 1ST SINGLE ANTB STN","code_information":[{"code":"88346","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88346","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG ELECTRON MICROSCOPY DIAGNOSTIC","code_information":[{"code":"88348","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88348","type":"HCPCS"}],"standard_charges":[{"gross_charge":2537.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IMMUNOFLUORESCENCE PR SPEC EA ADD SINGL ANTB STN","code_information":[{"code":"88350","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MORPHOMETRIC ANALYSIS NERVE","code_information":[{"code":"88356","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88356","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG M/PHMTRC ALYS TUMOR IMHCHEM EA ANTIBODY MANUAL","code_information":[{"code":"88360","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":667.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG M/PHMTRC ALYS TUMOR IMHCHEM EA ANTBDY CMPTR ASST","code_information":[{"code":"88361","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88361","type":"HCPCS"}],"standard_charges":[{"gross_charge":1117.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IN SITU HYBRIDIZATION EA ADDL PROBE STAIN","code_information":[{"code":"88364","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88364","type":"HCPCS"}],"standard_charges":[{"gross_charge":344.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG IN SITU HYBRIDIZATION 1ST PROBE STAIN","code_information":[{"code":"88365","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88365","type":"HCPCS"}],"standard_charges":[{"gross_charge":339.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN","code_information":[{"code":"88367","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88367","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR EACH MULTIPRB","code_information":[{"code":"88374","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88374","type":"HCPCS"}],"standard_charges":[{"gross_charge":580.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH MULTIPRB","code_information":[{"code":"88377","type":"CDM"},{"code":"0312","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":736.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MICRODISSECTION PREP IDENTIFIED TARGET MANUAL","code_information":[{"code":"88381","type":"CDM"},{"code":"0310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT","code_information":[{"code":"89051","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89051","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE","code_information":[{"code":"89055","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89055","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG CRYSTAL ID LIGHT MICROSCOPY ALYS TISS/ANY FLUID","code_information":[{"code":"89060","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89060","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG FAT STAIN FECES URINE/RESPIR SECRETIONS","code_information":[{"code":"89125","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89125","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG MEAT FIBERS FECES","code_information":[{"code":"89160","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89160","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG NASAL SMEAR EOSINOPHILS","code_information":[{"code":"89190","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89190","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG UNLISTED MISCELLANEOUS PATHOLOGY TEST","code_information":[{"code":"89240","type":"CDM"},{"code":"0310","type":"RC"},{"code":"89240","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SEMEN ALYS MOTILITY&CNT X W/HUHNER TST","code_information":[{"code":"89310","type":"CDM"},{"code":"0309","type":"RC"},{"code":"89310","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT","code_information":[{"code":"89320","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89320","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM","code_information":[{"code":"89321","type":"CDM"},{"code":"0300","type":"RC"},{"code":"89321","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCH DIAG EVAL","code_information":[{"code":"9000000001","type":"CDM"},{"code":"0900","type":"RC"},{"code":"90791","type":"HCPCS"}],"standard_charges":[{"gross_charge":762.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCH DIAG EVAL W MED SVCS","code_information":[{"code":"9000000002","type":"CDM"},{"code":"0900","type":"RC"},{"code":"90792","type":"HCPCS"}],"standard_charges":[{"gross_charge":762.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCHOTHERAPY, 30 MINUTES WITH PATIENT","code_information":[{"code":"9000000003","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90832","type":"HCPCS"}],"standard_charges":[{"gross_charge":762.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCH PT W FAMILY W EM 30 MINS","code_information":[{"code":"9000000004","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90833","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCHCHOTHERAPY, 45 MINUTES WITH PATIENT","code_information":[{"code":"9000000005","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90834","type":"HCPCS"}],"standard_charges":[{"gross_charge":762.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCH THERAPY PT W FAMILY W EM 45 MINS","code_information":[{"code":"9000000006","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90836","type":"HCPCS"}],"standard_charges":[{"gross_charge":273.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCHOTHERAPY, 60 MINUTES WITH PATIENT","code_information":[{"code":"9000000007","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90837","type":"HCPCS"}],"standard_charges":[{"gross_charge":762.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCH THERAPY PAT W FAM W EM 60 MIN","code_information":[{"code":"9000000008","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90838","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCH THERAPY CRISIS INIT 60 MIN","code_information":[{"code":"9000000009","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90839","type":"HCPCS"}],"standard_charges":[{"gross_charge":535.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYTHERAPY CRISIS EA ADD 30 MINS","code_information":[{"code":"9000000010","type":"CDM"},{"code":"0914","type":"RC"},{"code":"90840","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARE MGMT SERVICES BEHAVIORAL HLTH COND 20 MINS","code_information":[{"code":"9000000018","type":"CDM"},{"code":"0900","type":"RC"},{"code":"99484","type":"HCPCS"}],"standard_charges":[{"gross_charge":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC 1ST PSYCHIATRIC COLLAB CARE MGMT 70 MINS","code_information":[{"code":"9000000019","type":"CDM"},{"code":"0900","type":"RC"},{"code":"99492","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CRISIS INTERVENTION MENTAL HEALTH","code_information":[{"code":"9110000000","type":"CDM"},{"code":"0911","type":"RC"},{"code":"S9485","type":"HCPCS"}],"standard_charges":[{"gross_charge":1027.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEALTH BEHAVIOR IVNTJ INDIV F2F 1ST 30 MIN","code_information":[{"code":"9140000007","type":"CDM"},{"code":"0914","type":"RC"},{"code":"96158","type":"HCPCS"}],"standard_charges":[{"gross_charge":499.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEALTH BEHAVIOR IVNTJ INDIV F2F EA ADDL 15 MIN","code_information":[{"code":"9140000008","type":"CDM"},{"code":"0914","type":"RC"},{"code":"96159","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC RISK ASCVD TEST ONCE PR 12 MONTHS","code_information":[{"code":"9140000009","type":"CDM"},{"code":"0914","type":"RC"},{"code":"G0537","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ASCVD RISK MNGMT CLIN STAFF P/MONTH","code_information":[{"code":"9140000010","type":"CDM"},{"code":"0914","type":"RC"},{"code":"G0538","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GROUP PSYCH THER","code_information":[{"code":"9150000000","type":"CDM"},{"code":"0915","type":"RC"},{"code":"90853","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEALTH BEHAVIOR IVNTJ FAM W PT F2F 1ST 30 MIN","code_information":[{"code":"9160000003","type":"CDM"},{"code":"0916","type":"RC"},{"code":"96167","type":"HCPCS"}],"standard_charges":[{"gross_charge":72.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HEALTH BEHAVIOR ASSESSMENT RE-ASSESSMENT","code_information":[{"code":"9180000001","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96156","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GONIOSCOPY","code_information":[{"code":"9200000000","type":"CDM"},{"code":"0510","type":"RC"},{"code":"92020","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VISUAL FIELD EXAM EXT","code_information":[{"code":"9200000007","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92083","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OPHTHALMIC POSTERIOR SEG OPTIC NERVE","code_information":[{"code":"9200000010","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92133","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FLUORESCEIN ANGIOGRAPHY","code_information":[{"code":"9200000015","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92235","type":"HCPCS"}],"standard_charges":[{"gross_charge":620.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FUNDUS PHOTOGRAPHY","code_information":[{"code":"9200000016","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92250","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC COLOR VISION EXAM EXT","code_information":[{"code":"9200000017","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92283","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC AMBULATORY BP MONITOR REC ONLY","code_information":[{"code":"9200000022","type":"CDM"},{"code":"0920","type":"RC"},{"code":"93786","type":"HCPCS"}],"standard_charges":[{"gross_charge":333.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN EXTACRANIAL ART COMP","code_information":[{"code":"9200000023","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93880","type":"HCPCS"}],"standard_charges":[{"gross_charge":790.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN EXTACRANIAL ART LTD","code_information":[{"code":"9200000024","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93882","type":"HCPCS"}],"standard_charges":[{"gross_charge":816.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCRANIAL DOPPLER CMPLT","code_information":[{"code":"9200000025","type":"CDM"},{"code":"0920","type":"RC"},{"code":"93886","type":"HCPCS"}],"standard_charges":[{"gross_charge":1310.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON INVASIVE STUDY UPPER LOW EXT SINGLE","code_information":[{"code":"9200000026","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93922","type":"HCPCS"}],"standard_charges":[{"gross_charge":467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON INVASIVE STUDY UPPER LOW EXT COMP","code_information":[{"code":"9200000027","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93923","type":"HCPCS"}],"standard_charges":[{"gross_charge":777.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NON INVASIVE STUDY LOWER EXT COMP BI","code_information":[{"code":"9200000028","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93924","type":"HCPCS"}],"standard_charges":[{"gross_charge":897.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN LWER EXT ART COMP","code_information":[{"code":"9200000029","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93925","type":"HCPCS"}],"standard_charges":[{"gross_charge":793.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN LOWER EXT ART LIM","code_information":[{"code":"9200000030","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93926","type":"HCPCS"}],"standard_charges":[{"gross_charge":748.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN UPPER EXT ART COMP","code_information":[{"code":"9200000031","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93930","type":"HCPCS"}],"standard_charges":[{"gross_charge":901.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN UPPER EXT ART LIM","code_information":[{"code":"9200000032","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93931","type":"HCPCS"}],"standard_charges":[{"gross_charge":625.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN EXT VEIN COMP","code_information":[{"code":"9200000034","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93970","type":"HCPCS"}],"standard_charges":[{"gross_charge":974.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN EXT VEIN LTD","code_information":[{"code":"9200000035","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93971","type":"HCPCS"}],"standard_charges":[{"gross_charge":840.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN ART INFLOW OUTFLOW","code_information":[{"code":"9200000036","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93975","type":"HCPCS"}],"standard_charges":[{"gross_charge":679.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN ART IN VENOUS OUT LTD","code_information":[{"code":"9200000037","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93976","type":"HCPCS"}],"standard_charges":[{"gross_charge":679.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN AORTA COMP","code_information":[{"code":"9200000038","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93978","type":"HCPCS"}],"standard_charges":[{"gross_charge":973.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN AORTA IVC LTD","code_information":[{"code":"9200000039","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93979","type":"HCPCS"}],"standard_charges":[{"gross_charge":470.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN PENILE VSLS COMP","code_information":[{"code":"9200000040","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93980","type":"HCPCS"}],"standard_charges":[{"gross_charge":722.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUP SCAN OF HEMODIALYSIS ACC","code_information":[{"code":"9200000041","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93990","type":"HCPCS"}],"standard_charges":[{"gross_charge":679.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MULTI SLEEP LATENCY STUDY","code_information":[{"code":"9200000043","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95805","type":"HCPCS"}],"standard_charges":[{"gross_charge":2640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SLEEP STUDY UNATTENDED","code_information":[{"code":"9200000044","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95806","type":"HCPCS"}],"standard_charges":[{"gross_charge":1157.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC POLYSOMNOGRAPHY  W 4 PLUS PARAMETERS","code_information":[{"code":"9200000045","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95810","type":"HCPCS"}],"standard_charges":[{"gross_charge":2919.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC POLYSOMNOGRAPHY  W 4 PLUS PARAMATERS W INIT","code_information":[{"code":"9200000046","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95811","type":"HCPCS"}],"standard_charges":[{"gross_charge":2640.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ANALYSIS IMPLANT NEUROSTM WO RPT","code_information":[{"code":"9200000048","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95970","type":"HCPCS"}],"standard_charges":[{"gross_charge":533.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELEC ALYS NSTIM PLS GEN CPLX SC OR PERPH 1ST HR","code_information":[{"code":"9200000049","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95972","type":"HCPCS"}],"standard_charges":[{"gross_charge":1031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INTERSTIM STAGE 2 ELECT ANALYSIS","code_information":[{"code":"9200000055","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95972","type":"HCPCS"}],"standard_charges":[{"gross_charge":1031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FULL FIELD ELECTRORETINOGRAPHY W I&R","code_information":[{"code":"9200000066","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92273","type":"HCPCS"}],"standard_charges":[{"gross_charge":892.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MULTIFOCAL ELECTRORETINOGRAPHY W I&R","code_information":[{"code":"9200000067","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92274","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELEC ALYS IMPLT SIMPLE CN NPGT PRGRMG","code_information":[{"code":"9200000070","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95976","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELEC ALYS IMPLT COMPLEX CN NPGT PRGRMG","code_information":[{"code":"9200000071","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95977","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELEC ALYS IMPLT BRN NPGT PRGRMG 1ST 15 MIN","code_information":[{"code":"9200000072","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95983","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELEC ALYS IMPLT BRN NPGT PRGRMG EA ADDL 15 MIN","code_information":[{"code":"9200000073","type":"CDM"},{"code":"0920","type":"RC"},{"code":"95984","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DEVELOPMENTAL TST ADMIN BY PHYS QHP 1ST HOUR","code_information":[{"code":"9200000074","type":"CDM"},{"code":"0920","type":"RC"},{"code":"96112","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEUROBEHAVIORAL STATUS EXAM BY PHYS QHP EA ADDL HOUR","code_information":[{"code":"9200000076","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96121","type":"HCPCS"}],"standard_charges":[{"gross_charge":213.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCHOLOGICAL TST EVAL SVC BY PHYS QHP FIRST HOUR","code_information":[{"code":"9200000077","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96130","type":"HCPCS"}],"standard_charges":[{"gross_charge":464.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEUROPSYCHOLOGICAL TST EVAL BY PHYS QHP 1ST HOUR","code_information":[{"code":"9200000079","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96132","type":"HCPCS"}],"standard_charges":[{"gross_charge":464.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCL NRPSYCL TST BY PHYS QHP 2+ TST 1ST 30 MIN","code_information":[{"code":"9200000081","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96136","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCL NRPSYCL TST BY PHYS QHP 2+ TST EA ADDL 30 MIN","code_information":[{"code":"9200000082","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96137","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCL NRPSYCL TST BY TECH 2+ TESTS 1ST 30 MIN","code_information":[{"code":"9200000083","type":"CDM"},{"code":"0918","type":"RC"},{"code":"96138","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PSYCL NRPSYCL TST ELEC PLATFORM AUTO RESULT","code_information":[{"code":"9200000085","type":"CDM"},{"code":"0920","type":"RC"},{"code":"96146","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BEHAVIOR ID ASSESSMENT BY PHYS QHP EA 15 MIN","code_information":[{"code":"9200000086","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97151","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC BEHAVIOR ID SUPPORT ASSMT BY 1 TECH EA 15 MIN","code_information":[{"code":"9200000087","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97152","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN","code_information":[{"code":"9200000088","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97153","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GROUP ADAPTIVE BEHAV TX BY PROTOCOL TECH EA 15 MIN","code_information":[{"code":"9200000089","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97154","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ADAPT BEHAV TX PRTCL MODIFICAJ PHYS QHP EA 15 MIN","code_information":[{"code":"9200000090","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97155","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC FAMILY ADAPT BEHAV TX GDN PHYS QHP EA 15 MIN","code_information":[{"code":"9200000091","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97156","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MULTIPLE FAM GROUP BEHAV TX GDN PHYS QHP EA 15 MIN","code_information":[{"code":"9200000092","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97157","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GRP ADAPT BEHAV TX W PRTCL MOD BY PHYS QHP EA 15 MIN","code_information":[{"code":"9200000093","type":"CDM"},{"code":"0920","type":"RC"},{"code":"97158","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MAC PGMT OPTICAL DNS MEAS HFP UNI BI W I&R","code_information":[{"code":"9200000094","type":"CDM"},{"code":"0920","type":"RC"},{"code":"0506T","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NEAR INFRARED DUAL IMG MEIBOMIAN GLND UNI BI I&R","code_information":[{"code":"9200000095","type":"CDM"},{"code":"0920","type":"RC"},{"code":"0507T","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PATTERN ELECTRORETINOGRAPHY W I&R","code_information":[{"code":"9200000096","type":"CDM"},{"code":"0920","type":"RC"},{"code":"0509T","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUOPA PROGRAMMING 1ST 15 MIN","code_information":[{"code":"9200000100","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":917.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DUOPA PROGRAMMING EA ADDTL 15 MIN","code_information":[{"code":"9200000101","type":"CDM"},{"code":"0510","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":295.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CERVICAL & OCULAR VEMP TESTING W/I&R","code_information":[{"code":"9200000108","type":"CDM"},{"code":"0920","type":"RC"},{"code":"92519","type":"HCPCS"}],"standard_charges":[{"gross_charge":990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SCREENING TEST OF VISUAL ACUITY, QUANTITATIVE, BILATERAL","code_information":[{"code":"9200000115","type":"CDM"},{"code":"0920","type":"RC"},{"code":"99173","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC HOME SLEEP TEST/TYPE 3 PORTA","code_information":[{"code":"9200000118","type":"CDM"},{"code":"0920","type":"RC"},{"code":"G0399","type":"HCPCS"}],"standard_charges":[{"gross_charge":584.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VASOREACTIVITY STUDY W/TCD ICR ARTERIES COMPLETE","code_information":[{"code":"9200000119","type":"CDM"},{"code":"0920","type":"RC"},{"code":"93896","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMBOLI DETECT W/O IV MBUBBLE INJ TCD ICR ART COMPL","code_information":[{"code":"9200000120","type":"CDM"},{"code":"0920","type":"RC"},{"code":"93897","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC VEN-ARTL SHNT DETC IV MBUBBLE INJ TCD ICR ART COMPLETE","code_information":[{"code":"9200000121","type":"CDM"},{"code":"0920","type":"RC"},{"code":"93898","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC TRANSCRAN DOPPLER INTRACRAN,LIMITED","code_information":[{"code":"9210000001","type":"CDM"},{"code":"0921","type":"RC"},{"code":"93888","type":"HCPCS"}],"standard_charges":[{"gross_charge":379.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMG NEEDLE 1 EXT","code_information":[{"code":"9220000001","type":"CDM"},{"code":"0922","type":"RC"},{"code":"95860","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EMG NEEDLE FOR CHEMODENERVATION","code_information":[{"code":"9220000007","type":"CDM"},{"code":"0922","type":"RC"},{"code":"95874","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MUSCLE TEST W NEEDLE NON-EXT","code_information":[{"code":"9220000010","type":"CDM"},{"code":"0922","type":"RC"},{"code":"95887","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOTOR SENS 1 TO 2 NERVE CONDUCTION STUDY","code_information":[{"code":"9220000011","type":"CDM"},{"code":"0922","type":"RC"},{"code":"95907","type":"HCPCS"}],"standard_charges":[{"gross_charge":515.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOTOR SENS 5 TO 6 NERVE CONDUCTION STUDY","code_information":[{"code":"9220000013","type":"CDM"},{"code":"0922","type":"RC"},{"code":"95909","type":"HCPCS"}],"standard_charges":[{"gross_charge":807.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB","code_information":[{"code":"9220000039","type":"CDM"},{"code":"0922","type":"RC"},{"code":"95905","type":"HCPCS"}],"standard_charges":[{"gross_charge":1197.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC ELECTRICAL STIM GUID W/CHEMODE","code_information":[{"code":"9221000001","type":"CDM"},{"code":"0510","type":"RC"},{"code":"95873","type":"HCPCS"}],"standard_charges":[{"gross_charge":126.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SCREENING PAP SMEAR","code_information":[{"code":"9230000000","type":"CDM"},{"code":"0923","type":"RC"},{"code":"Q0091","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJ THERAPEUTIC SUBC IM","code_information":[{"code":"9400000011","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96372","type":"HCPCS"}],"standard_charges":[{"gross_charge":126.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV PUSH INIT DRUG","code_information":[{"code":"9400000012","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96374","type":"HCPCS"}],"standard_charges":[{"gross_charge":346.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IV PUSH ADDL SEQ NEW DRUG","code_information":[{"code":"9400000013","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96375","type":"HCPCS"}],"standard_charges":[{"gross_charge":126.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EA ADD IV PUSH OF SAME DRUG","code_information":[{"code":"9400000014","type":"CDM"},{"code":"0260","type":"RC"},{"code":"96376","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC IRRIGATE IMPL VENOUS ACC DEV DRUG DEL","code_information":[{"code":"9400000015","type":"CDM"},{"code":"0940","type":"RC"},{"code":"96523","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHLEBOTOMY THERAPEUTIC","code_information":[{"code":"9400000019","type":"CDM"},{"code":"0940","type":"RC"},{"code":"99195","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC INJECT THER DX INTRA ARTERIAL","code_information":[{"code":"9400000032","type":"CDM"},{"code":"0940","type":"RC"},{"code":"96373","type":"HCPCS"}],"standard_charges":[{"gross_charge":467.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC GENETIC COUNSELING EA 30M","code_information":[{"code":"9400000038","type":"CDM"},{"code":"0940","type":"RC"},{"code":"96040","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION","code_information":[{"code":"9400000044","type":"CDM"},{"code":"0940","type":"RC"},{"code":"96377","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC MED GENETICS&GENETIC COUNSELING SVCS EACH 30 MIN","code_information":[{"code":"9400000052","type":"CDM"},{"code":"0940","type":"RC"},{"code":"96041","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NUTRITION THERAPY INIT ASSESS EA 15 MIN","code_information":[{"code":"9420000000","type":"CDM"},{"code":"0942","type":"RC"},{"code":"97802","type":"HCPCS"}],"standard_charges":[{"gross_charge":101.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NUTRITION THERAPY REASSESSMENT 15 MIN","code_information":[{"code":"9420000001","type":"CDM"},{"code":"0942","type":"RC"},{"code":"97803","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NUTRITION THERAPY GRP 30 MIN","code_information":[{"code":"9420000002","type":"CDM"},{"code":"0942","type":"RC"},{"code":"97804","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMOKING CESSATION SYMPTOM 3 TO 10 MIN","code_information":[{"code":"9420000003","type":"CDM"},{"code":"0942","type":"RC"},{"code":"99406","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC SMOKING CESSATION SYMPTOM MORE THAN 10 MIN","code_information":[{"code":"9420000004","type":"CDM"},{"code":"0942","type":"RC"},{"code":"99407","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC DIABETES SELF MANAGE IND 30 MIN","code_information":[{"code":"9420000005","type":"CDM"},{"code":"0942","type":"RC"},{"code":"G0108","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NUTRITION THERAPY SUBS 15 MIN","code_information":[{"code":"9420000007","type":"CDM"},{"code":"0942","type":"RC"},{"code":"G0270","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC NUTRITION THERAPY SUBS GROUP","code_information":[{"code":"9420000008","type":"CDM"},{"code":"0942","type":"RC"},{"code":"G0271","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC EDUCATION&TRAINING SELF-MGMT NONPHYS 1 PT","code_information":[{"code":"9420000013","type":"CDM"},{"code":"0942","type":"RC"},{"code":"98960","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIAC REHAB WO ECG MON","code_information":[{"code":"9430000000","type":"CDM"},{"code":"0943","type":"RC"},{"code":"93797","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC CARDIAC REHAB W ECG MON","code_information":[{"code":"9430000001","type":"CDM"},{"code":"0943","type":"RC"},{"code":"93798","type":"HCPCS"}],"standard_charges":[{"gross_charge":400.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYS/QHP SVCS OP PULM REHAB WO CONT OXIMTRY MNTR","code_information":[{"code":"9480000001","type":"CDM"},{"code":"0948","type":"RC"},{"code":"94625","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PHYS/QHP SVCS OP PULM REHAB W/CONT OXIMTRY MNTR","code_information":[{"code":"9480000002","type":"CDM"},{"code":"0948","type":"RC"},{"code":"94626","type":"HCPCS"}],"standard_charges":[{"gross_charge":167.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC PATHOLOGIST - FNA INTERP (PC)","code_information":[{"code":"9711000000","type":"CDM"},{"code":"0311","type":"RC"},{"code":"88173","type":"HCPCS"}],"standard_charges":[{"gross_charge":283.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"HC OVERNIGHT ROOM & BOARD-HINN PT","code_information":[{"code":"9901000000","type":"CDM"},{"code":"0990","type":"RC"},{"code":"9901000000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1013.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG PATHOGEN TEST FOR PLATELETS","code_information":[{"code":"P9100","type":"CDM"},{"code":"0300","type":"RC"},{"code":"P9100","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"CHG COVID-19 LAB TEST NON-CDC","code_information":[{"code":"U0002","type":"CDM"},{"code":"0306","type":"RC"},{"code":"U0002","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: standard"}]},{"description":"Carotid Artery Stent Procedures With Mcc","code_information":[{"code":"034","type":"MS-DRG"}],"standard_charges":[{"minimum":32598.56,"maximum":32598.56,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32598.56,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Carotid Artery Stent Procedures Without Cc/Mcc","code_information":[{"code":"036","type":"MS-DRG"}],"standard_charges":[{"minimum":15274.38,"maximum":15274.38,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15274.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Extracranial Procedures With Cc","code_information":[{"code":"038","type":"MS-DRG"}],"standard_charges":[{"minimum":7905.29,"maximum":13526.48,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7905.29,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13526.48,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13416.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Extracranial Procedures Without Cc/Mcc","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"minimum":9564.48,"maximum":9564.48,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9564.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","code_information":[{"code":"040","type":"MS-DRG"}],"standard_charges":[{"minimum":31627.17,"maximum":31627.17,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":31627.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","code_information":[{"code":"041","type":"MS-DRG"}],"standard_charges":[{"minimum":36068.24,"maximum":36068.24,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":36068.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Nervous System Neoplasms With Mcc","code_information":[{"code":"054","type":"MS-DRG"}],"standard_charges":[{"minimum":12554.21,"maximum":12554.21,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12554.21,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"minimum":21003.22,"maximum":21003.22,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21003.22,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Degenerative Nervous System Disorders Without Mcc","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"minimum":11174.93,"maximum":11174.93,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11174.93,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Mcc","code_information":[{"code":"058","type":"MS-DRG"}],"standard_charges":[{"minimum":15390.53,"maximum":15390.53,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15390.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","code_information":[{"code":"060","type":"MS-DRG"}],"standard_charges":[{"minimum":7506.05,"maximum":7506.05,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7506.05,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"minimum":16563.66,"maximum":16658.56,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16658.56,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16563.66,"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":1185.0,"maximum":8515.91,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1185.0,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8515.91,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8478.46,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8490.25,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":6083.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","code_information":[{"code":"066","type":"MS-DRG"}],"standard_charges":[{"minimum":5796.81,"maximum":5796.81,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5796.81,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Transient Ischemia Without Thrombolytic","code_information":[{"code":"069","type":"MS-DRG"}],"standard_charges":[{"minimum":5507.41,"maximum":19009.99,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":14622.97,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":19009.99,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8311.43,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6733.09,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5507.41,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6922.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Cerebrovascular Disorders With Mcc","code_information":[{"code":"070","type":"MS-DRG"}],"standard_charges":[{"minimum":12962.21,"maximum":17289.55,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":17289.55,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12962.21,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Cerebrovascular Disorders With Cc","code_information":[{"code":"071","type":"MS-DRG"}],"standard_charges":[{"minimum":8858.53,"maximum":9096.99,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8858.53,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9096.99,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cranial And Peripheral Nerve Disorders With Mcc","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"minimum":11635.72,"maximum":11635.72,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11635.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cranial And Peripheral Nerve Disorders Without Mcc","code_information":[{"code":"074","type":"MS-DRG"}],"standard_charges":[{"minimum":7130.23,"maximum":15683.53,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8716.17,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":15683.53,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7130.23,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8690.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Viral Meningitis With Cc/Mcc","code_information":[{"code":"075","type":"MS-DRG"}],"standard_charges":[{"minimum":13707.57,"maximum":13707.57,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13707.57,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Viral Meningitis Without Cc/Mcc","code_information":[{"code":"076","type":"MS-DRG"}],"standard_charges":[{"minimum":7105.0,"maximum":28720.78,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":7105.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28720.78,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hypertensive Encephalopathy With Mcc","code_information":[{"code":"077","type":"MS-DRG"}],"standard_charges":[{"minimum":11308.72,"maximum":11308.72,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11308.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Nontraumatic Stupor And Coma With Mcc","code_information":[{"code":"080","type":"MS-DRG"}],"standard_charges":[{"minimum":16646.82,"maximum":16646.82,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16646.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Traumatic Stupor And Coma >1 Hour With Mcc","code_information":[{"code":"082","type":"MS-DRG"}],"standard_charges":[{"minimum":19459.91,"maximum":19459.91,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19459.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Traumatic Stupor And Coma <1 Hour With Mcc","code_information":[{"code":"085","type":"MS-DRG"}],"standard_charges":[{"minimum":19009.87,"maximum":19009.87,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19009.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"minimum":13666.51,"maximum":13666.51,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13666.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"minimum":8866.08,"maximum":17324.89,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":17324.89,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8866.08,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Disorders Of Nervous System Without Cc/Mcc","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"minimum":6320.39,"maximum":17324.89,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":17324.89,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8717.78,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":6320.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Seizures Without Mcc","code_information":[{"code":"101","type":"MS-DRG"}],"standard_charges":[{"minimum":7751.41,"maximum":10187.91,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10187.91,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7751.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Headaches With Mcc","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"minimum":6522.31,"maximum":9366.42,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6522.31,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9366.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"minimum":6522.31,"maximum":20860.57,"setting":"inpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":20860.57,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6522.31,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Neurological Eye Disorders","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"minimum":5127.03,"maximum":5127.03,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5127.03,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Disorders Of The Eye Without Mcc","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"minimum":6948.24,"maximum":7651.79,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":7651.79,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6948.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Mcc","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"minimum":6670.98,"maximum":6670.98,"setting":"inpatient","payers_information":[{"payer_name":"Medicare Advantage","plan_name":"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":6670.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"minimum":4660.58,"maximum":15921.24,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":15921.24,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4660.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6223.43,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6237.22,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Otitis Media And Uri With Mcc","code_information":[{"code":"152","type":"MS-DRG"}],"standard_charges":[{"minimum":9453.97,"maximum":9453.97,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9453.97,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Otitis Media And Uri Without Mcc","code_information":[{"code":"153","type":"MS-DRG"}],"standard_charges":[{"minimum":4415.76,"maximum":6282.95,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6282.95,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4415.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"minimum":13619.44,"maximum":13619.44,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13619.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","code_information":[{"code":"155","type":"MS-DRG"}],"standard_charges":[{"minimum":1100.0,"maximum":7851.08,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7851.08,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1100.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"minimum":7909.7,"maximum":7909.7,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7909.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","code_information":[{"code":"175","type":"MS-DRG"}],"standard_charges":[{"minimum":11731.51,"maximum":11800.51,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11800.51,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11731.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Embolism Without Mcc","code_information":[{"code":"176","type":"MS-DRG"}],"standard_charges":[{"minimum":6530.96,"maximum":16718.04,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":16718.04,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6625.95,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":6530.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Infections And Inflammations With Mcc","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"minimum":8259.88,"maximum":34718.65,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13458.42,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8259.88,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":34718.65,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":31245.62,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13462.59,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29347.35,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15509.92,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11938.03,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12918.39,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8785.57,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13458.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Infections And Inflammations With Cc","code_information":[{"code":"178","type":"MS-DRG"}],"standard_charges":[{"minimum":8290.28,"maximum":9309.65,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9309.65,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8308.34,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8290.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"minimum":6424.76,"maximum":6478.5,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6478.5,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6424.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"minimum":14554.32,"maximum":14638.92,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14638.92,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14554.32,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":14604.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Chest Trauma With Mcc","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"minimum":13292.86,"maximum":13292.86,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13292.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Chest Trauma With Cc","code_information":[{"code":"184","type":"MS-DRG"}],"standard_charges":[{"minimum":7303.52,"maximum":7303.52,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7303.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Chest Trauma Without Cc/Mcc","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"minimum":6480.85,"maximum":6480.85,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6480.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Edema And Respiratory Failure","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"minimum":1110.0,"maximum":14827.5,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1110.0,"methodology":"other"},{"payer_name":"Aetna","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":13660.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":4077.02,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12252.46,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10362.62,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":10614.23,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14827.5,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10302.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"minimum":6163.25,"maximum":23322.3,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9347.59,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":17940.11,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":23322.3,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9382.72,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17717.27,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6899.73,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":9629.04,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6163.25,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9361.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"minimum":7227.17,"maximum":7438.67,"setting":"inpatient","payers_information":[{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7438.67,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7227.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","code_information":[{"code":"192","type":"MS-DRG"}],"standard_charges":[{"minimum":4918.26,"maximum":4918.26,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4918.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"minimum":5233.87,"maximum":29241.35,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8236.44,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5233.87,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":29241.35,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":25274.03,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11034.92,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":11298.48,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9865.28,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10976.71,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12542.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11001.37,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":10735.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"minimum":2182.52,"maximum":25274.03,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6848.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":14026.11,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":25274.03,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":9154.53,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2182.52,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11871.61,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4263.07,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6899.73,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6833.04,"methodology":"other"},{"payer_name":"Tufts 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":9615.96,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7012.49,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"minimum":3572.31,"maximum":18234.07,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":18234.07,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8990.78,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3572.31,"methodology":"other"},{"payer_name":"Tufts 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":14423.94,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Interstitial Lung Disease With Mcc","code_information":[{"code":"196","type":"MS-DRG"}],"standard_charges":[{"minimum":1900.0,"maximum":15814.02,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15814.02,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1900.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pneumothorax With Mcc","code_information":[{"code":"199","type":"MS-DRG"}],"standard_charges":[{"minimum":14783.5,"maximum":14783.5,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14783.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pneumothorax With Cc","code_information":[{"code":"200","type":"MS-DRG"}],"standard_charges":[{"minimum":9307.4,"maximum":9307.4,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9307.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pneumothorax Without Cc/Mcc","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"minimum":5653.85,"maximum":5653.85,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5653.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"minimum":2732.0,"maximum":27005.43,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2732.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":27005.43,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":19976.9,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9154.53,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15180.43,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7110.25,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8095.63,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":8288.87,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7110.26,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8076.41,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6271.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7110.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Bronchitis And Asthma Without Cc/Mcc","code_information":[{"code":"203","type":"MS-DRG"}],"standard_charges":[{"minimum":2828.0,"maximum":8535.73,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2828.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3051.51,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5834.08,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8535.73,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8535.73,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4307.8,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5532.43,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6271.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5532.43,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"minimum":13284.02,"maximum":14052.96,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14052.96,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13284.02,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Respiratory System Diagnoses Without Mcc","code_information":[{"code":"206","type":"MS-DRG"}],"standard_charges":[{"minimum":6915.92,"maximum":9296.15,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9296.15,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6915.92,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"minimum":5132.93,"maximum":22960.48,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5132.93,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22960.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","code_information":[{"code":"221","type":"MS-DRG"}],"standard_charges":[{"minimum":9734.35,"maximum":9734.35,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":9734.35,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Vascular Procedures With Cc","code_information":[{"code":"253","type":"MS-DRG"}],"standard_charges":[{"minimum":21255.39,"maximum":41577.14,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21303.65,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21271.1,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":41577.14,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21380.1,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21255.39,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21922.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","code_information":[{"code":"255","type":"MS-DRG"}],"standard_charges":[{"minimum":25036.12,"maximum":25036.12,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25036.12,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Circulatory System O.R. Procedures","code_information":[{"code":"264","type":"MS-DRG"}],"standard_charges":[{"minimum":1233.02,"maximum":1233.02,"setting":"inpatient","payers_information":[{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1233.02,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","code_information":[{"code":"268","type":"MS-DRG"}],"standard_charges":[{"minimum":55547.0,"maximum":55547.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":55547.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Major Cardiovascular Procedures With Mcc","code_information":[{"code":"270","type":"MS-DRG"}],"standard_charges":[{"minimum":43018.95,"maximum":85965.62,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":85965.62,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43018.95,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Major Cardiovascular Procedures With Cc","code_information":[{"code":"271","type":"MS-DRG"}],"standard_charges":[{"minimum":21922.42,"maximum":35486.43,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35486.43,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21922.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"minimum":13665.73,"maximum":13745.71,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13669.97,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13745.71,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13665.73,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"minimum":1813.15,"maximum":7752.26,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":7013.12,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3051.51,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1813.15,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7752.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"minimum":2473.79,"maximum":8552.0,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":2473.79,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4472.98,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6036.93,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":8552.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Myocardial Infarction, Expired With Mcc","code_information":[{"code":"283","type":"MS-DRG"}],"standard_charges":[{"minimum":16408.15,"maximum":16408.15,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16408.15,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"minimum":8196.0,"maximum":139431.42,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10887.01,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10847.62,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8196.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":31940.97,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":11160.57,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8358.65,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":20943.71,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10909.69,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":11187.87,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":139431.42,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10863.31,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10863.31,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10355.99,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10876.87,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11218.43,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":10627.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Heart Failure And Shock With Cc","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"minimum":7245.54,"maximum":7245.54,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7245.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peripheral Vascular Disorders With Mcc","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"minimum":13579.22,"maximum":13579.22,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13579.22,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"minimum":8998.39,"maximum":8998.39,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8998.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Atherosclerosis Without Mcc","code_information":[{"code":"303","type":"MS-DRG"}],"standard_charges":[{"minimum":5663.65,"maximum":7453.11,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7453.11,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5663.65,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hypertension With Mcc","code_information":[{"code":"304","type":"MS-DRG"}],"standard_charges":[{"minimum":9838.37,"maximum":9838.37,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9838.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hypertension Without Mcc","code_information":[{"code":"305","type":"MS-DRG"}],"standard_charges":[{"minimum":4687.38,"maximum":17923.7,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":17923.7,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10368.18,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4687.38,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":6439.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"minimum":8245.07,"maximum":41428.05,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10039.91,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":41428.05,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":8245.07,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18987.92,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10131.45,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":10339.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"minimum":4591.9,"maximum":16888.15,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":12990.8,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":16888.15,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10933.5,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4591.9,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10933.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","code_information":[{"code":"310","type":"MS-DRG"}],"standard_charges":[{"minimum":4667.71,"maximum":12990.8,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":12990.8,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7569.62,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7569.62,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4718.17,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":4799.3,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4667.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Angina Pectoris","code_information":[{"code":"311","type":"MS-DRG"}],"standard_charges":[{"minimum":4205.44,"maximum":10573.53,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":10573.53,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4205.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Syncope And Collapse","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"minimum":4143.38,"maximum":16046.58,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7296.64,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":12343.44,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":16046.58,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7289.03,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4143.38,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7296.71,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":7473.88,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"minimum":2928.51,"maximum":13924.74,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":10711.26,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":13924.74,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2928.51,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6533.46,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5974.28,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":6119.43,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5939.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Circulatory System Diagnoses With Mcc","code_information":[{"code":"314","type":"MS-DRG"}],"standard_charges":[{"minimum":10289.36,"maximum":16435.12,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10289.36,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16435.12,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":14040.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Circulatory System Diagnoses With Cc","code_information":[{"code":"315","type":"MS-DRG"}],"standard_charges":[{"minimum":4975.02,"maximum":8058.79,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4975.02,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8058.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Mcc","code_information":[{"code":"326","type":"MS-DRG"}],"standard_charges":[{"minimum":20520.72,"maximum":20520.72,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20520.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Cc","code_information":[{"code":"327","type":"MS-DRG"}],"standard_charges":[{"minimum":20249.04,"maximum":20249.04,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20249.04,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","code_information":[{"code":"328","type":"MS-DRG"}],"standard_charges":[{"minimum":11745.41,"maximum":11745.41,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11745.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"minimum":12542.0,"maximum":36855.51,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":36855.51,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":12542.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Small And Large Bowel Procedures With Cc","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"minimum":8785.53,"maximum":77296.35,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":41596.27,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":77296.35,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":8785.53,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19827.44,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34823.06,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"331","type":"MS-DRG"}],"standard_charges":[{"minimum":30479.03,"maximum":44039.31,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":33876.16,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":44039.31,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30479.03,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Rectal Resection Without Cc/Mcc","code_information":[{"code":"334","type":"MS-DRG"}],"standard_charges":[{"minimum":5464.0,"maximum":5464.0,"setting":"inpatient","payers_information":[{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5464.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Peritoneal Adhesiolysis With Mcc","code_information":[{"code":"335","type":"MS-DRG"}],"standard_charges":[{"minimum":39581.76,"maximum":39581.76,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":39581.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Minor Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"minimum":10950.01,"maximum":10950.01,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10950.01,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Anal And Stomal Procedures With Cc","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"minimum":4263.0,"maximum":4263.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":4263.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inguinal And Femoral Hernia Procedures With Mcc","code_information":[{"code":"350","type":"MS-DRG"}],"standard_charges":[{"minimum":20288.04,"maximum":20288.04,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20288.04,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inguinal And Femoral Hernia Procedures With Cc","code_information":[{"code":"351","type":"MS-DRG"}],"standard_charges":[{"minimum":12527.11,"maximum":12527.11,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12527.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Mcc","code_information":[{"code":"353","type":"MS-DRG"}],"standard_charges":[{"minimum":24454.7,"maximum":24454.7,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24454.7,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System O.R. Procedures With Mcc","code_information":[{"code":"356","type":"MS-DRG"}],"standard_charges":[{"minimum":6519.99,"maximum":23198.59,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6519.99,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23198.59,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System O.R. Procedures With Cc","code_information":[{"code":"357","type":"MS-DRG"}],"standard_charges":[{"minimum":15911.9,"maximum":15911.9,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15911.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Esophageal Disorders With Cc","code_information":[{"code":"369","type":"MS-DRG"}],"standard_charges":[{"minimum":8554.53,"maximum":21158.82,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":21158.82,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8554.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"minimum":14638.62,"maximum":23083.39,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23083.39,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14638.62,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"minimum":4682.41,"maximum":22648.38,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":22648.38,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":20042.55,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":4682.41,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8619.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8602.66,"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":6108.37,"maximum":6108.37,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6108.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Digestive Malignancy With Mcc","code_information":[{"code":"374","type":"MS-DRG"}],"standard_charges":[{"minimum":13904.64,"maximum":17714.57,"setting":"inpatient","payers_information":[{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15696.08,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13904.64,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17714.57,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17590.83,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Digestive Malignancy With Cc","code_information":[{"code":"375","type":"MS-DRG"}],"standard_charges":[{"minimum":10535.36,"maximum":10535.36,"setting":"inpatient","payers_information":[{"payer_name":"Medicare Advantage","plan_name":"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":10535.36,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Hemorrhage With Mcc","code_information":[{"code":"377","type":"MS-DRG"}],"standard_charges":[{"minimum":15226.5,"maximum":31964.83,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":31964.83,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23394.92,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15226.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"minimum":2732.0,"maximum":19869.57,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8233.01,"methodology":"other"},{"payer_name":"Aetna","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":2732.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8227.44,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":19869.57,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":8453.49,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18806.76,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8256.41,"methodology":"other"},{"payer_name":"Medicare Advantage","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":8451.64,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":8456.89,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8212.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Hemorrhage Without Cc/Mcc","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"minimum":9459.83,"maximum":21928.63,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":15286.4,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":21928.63,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9459.83,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"minimum":14472.34,"maximum":16054.01,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16054.01,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14472.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Complicated Peptic Ulcer With Cc","code_information":[{"code":"381","type":"MS-DRG"}],"standard_charges":[{"minimum":6959.11,"maximum":7521.31,"setting":"inpatient","payers_information":[{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6959.11,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7521.31,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Uncomplicated Peptic Ulcer Without Mcc","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"minimum":1618.15,"maximum":31964.83,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":31964.83,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5683.1,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1618.15,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"minimum":2152.17,"maximum":13639.53,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2152.17,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13639.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"minimum":8513.51,"maximum":13572.8,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13572.8,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":8513.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammatory Bowel Disease Without Cc/Mcc","code_information":[{"code":"387","type":"MS-DRG"}],"standard_charges":[{"minimum":5646.96,"maximum":5646.96,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5646.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction With Mcc","code_information":[{"code":"388","type":"MS-DRG"}],"standard_charges":[{"minimum":12309.67,"maximum":12309.67,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12309.67,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"minimum":5071.41,"maximum":10895.2,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":10895.2,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5071.41,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6673.84,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":6423.16,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Gastrointestinal Obstruction Without Cc/Mcc","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"minimum":4561.79,"maximum":13820.29,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":10630.92,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":13820.29,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4589.85,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4561.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"minimum":3164.53,"maximum":39583.03,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10694.31,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":39583.03,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3164.53,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10726.95,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9116.01,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10697.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"minimum":1552.24,"maximum":16392.0,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6513.33,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16392.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":12416.9,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":16142.07,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":4882.4,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15363.45,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1552.24,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6498.53,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14621.17,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9104.54,"methodology":"other"},{"payer_name":"Healthpartners","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12206.04,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6567.26,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5464.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6529.15,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7049.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5429.09,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7852.02,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14621.17,"methodology":"other"},{"payer_name":"United Healthcare","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":2799.52,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":6174.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System Diagnoses With Mcc","code_information":[{"code":"393","type":"MS-DRG"}],"standard_charges":[{"minimum":12721.34,"maximum":21459.71,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13832.27,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21459.71,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13868.17,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12721.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System Diagnoses With Cc","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"minimum":6283.55,"maximum":12704.01,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6283.55,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12704.01,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Digestive System Diagnoses Without Cc/Mcc","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"minimum":16803.79,"maximum":16803.79,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":16803.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"minimum":3432.08,"maximum":38563.12,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":3432.08,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":38563.12,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12705.63,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"minimum":2904.0,"maximum":24214.61,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":24214.61,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6867.59,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10730.16,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2904.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cholecystectomy With C.D.E. With Cc","code_information":[{"code":"412","type":"MS-DRG"}],"standard_charges":[{"minimum":26151.71,"maximum":26151.71,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":26151.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","code_information":[{"code":"417","type":"MS-DRG"}],"standard_charges":[{"minimum":11758.91,"maximum":19934.65,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19934.65,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11758.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","code_information":[{"code":"418","type":"MS-DRG"}],"standard_charges":[{"minimum":13812.95,"maximum":39640.45,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13833.75,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13812.95,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":38683.15,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":39640.45,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13844.18,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":26151.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","code_information":[{"code":"419","type":"MS-DRG"}],"standard_charges":[{"minimum":1900.0,"maximum":40881.08,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":40881.08,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":11297.63,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1900.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":10734.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hepatobiliary Diagnostic Procedures With Mcc","code_information":[{"code":"420","type":"MS-DRG"}],"standard_charges":[{"minimum":29591.32,"maximum":29591.32,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29591.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","code_information":[{"code":"423","type":"MS-DRG"}],"standard_charges":[{"minimum":34062.44,"maximum":34062.44,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34062.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Cc","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"minimum":8959.05,"maximum":9172.9,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8959.05,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":9172.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"minimum":6809.41,"maximum":15312.75,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6809.41,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15312.75,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy With Mcc","code_information":[{"code":"438","type":"MS-DRG"}],"standard_charges":[{"minimum":11498.57,"maximum":23392.16,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":23392.16,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13884.02,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11498.57,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13965.29,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"minimum":4958.98,"maximum":30410.01,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":15366.74,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":30410.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":12091.56,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13072.24,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8914.22,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15784.64,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4958.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"minimum":15342.28,"maximum":15342.28,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":15342.28,"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":15521.18,"maximum":15863.8,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15863.8,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":15521.18,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"minimum":6492.08,"maximum":6492.08,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6492.08,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"443","type":"MS-DRG"}],"standard_charges":[{"minimum":5884.76,"maximum":5884.76,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5884.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of The Biliary Tract With Mcc","code_information":[{"code":"444","type":"MS-DRG"}],"standard_charges":[{"minimum":14138.64,"maximum":24524.97,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":24524.97,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14138.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of The Biliary Tract With Cc","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"minimum":9114.79,"maximum":23065.89,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13398.02,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23065.89,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9114.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Disorders Of The Biliary Tract Without Cc/Mcc","code_information":[{"code":"446","type":"MS-DRG"}],"standard_charges":[{"minimum":6676.99,"maximum":14484.66,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14484.66,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6676.99,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"463","type":"MS-DRG"}],"standard_charges":[{"minimum":45263.32,"maximum":45263.32,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":45263.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"464","type":"MS-DRG"}],"standard_charges":[{"minimum":24726.57,"maximum":24726.57,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24726.57,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"465","type":"MS-DRG"}],"standard_charges":[{"minimum":13879.55,"maximum":13879.55,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13879.55,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Revision Of Hip Or Knee Replacement With Mcc","code_information":[{"code":"466","type":"MS-DRG"}],"standard_charges":[{"minimum":28406.03,"maximum":95259.89,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":95259.89,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28406.03,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Revision Of Hip Or Knee Replacement With Cc","code_information":[{"code":"467","type":"MS-DRG"}],"standard_charges":[{"minimum":19020.2,"maximum":28548.11,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28548.11,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19020.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","code_information":[{"code":"468","type":"MS-DRG"}],"standard_charges":[{"minimum":21859.65,"maximum":21968.82,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21859.65,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21869.48,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21968.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","code_information":[{"code":"469","type":"MS-DRG"}],"standard_charges":[{"minimum":25734.91,"maximum":25734.91,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25734.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"minimum":15716.43,"maximum":43454.39,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":43454.39,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35014.5,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":31032.8,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15822.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15766.86,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15716.43,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16390.92,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","code_information":[{"code":"474","type":"MS-DRG"}],"standard_charges":[{"minimum":37595.63,"maximum":37595.63,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":37595.63,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hip And Femur Procedures Except Major Joint With Mcc","code_information":[{"code":"480","type":"MS-DRG"}],"standard_charges":[{"minimum":18535.19,"maximum":18535.19,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18535.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hip And Femur Procedures Except Major Joint With Cc","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"minimum":6870.29,"maximum":32182.68,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13207.81,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32182.68,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6870.29,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14647.14,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17302.4,"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":13320.6,"maximum":13320.6,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13320.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","code_information":[{"code":"483","type":"MS-DRG"}],"standard_charges":[{"minimum":22389.39,"maximum":22389.39,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":22389.39,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Mcc","code_information":[{"code":"485","type":"MS-DRG"}],"standard_charges":[{"minimum":1375.0,"maximum":1375.0,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1375.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"minimum":113260.69,"maximum":113260.69,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":113260.69,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"minimum":19083.25,"maximum":19083.25,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19083.25,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","code_information":[{"code":"494","type":"MS-DRG"}],"standard_charges":[{"minimum":13742.99,"maximum":13742.99,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13742.99,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Soft Tissue Procedures With Cc","code_information":[{"code":"501","type":"MS-DRG"}],"standard_charges":[{"minimum":13485.12,"maximum":25113.62,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13485.12,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25113.62,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Thumb Or Joint Procedures","code_information":[{"code":"506","type":"MS-DRG"}],"standard_charges":[{"minimum":18181.15,"maximum":18181.15,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":18181.15,"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":16328.75,"maximum":16328.75,"setting":"inpatient","payers_information":[{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16328.75,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","code_information":[{"code":"515","type":"MS-DRG"}],"standard_charges":[{"minimum":22501.15,"maximum":25746.24,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22501.15,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25746.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","code_information":[{"code":"516","type":"MS-DRG"}],"standard_charges":[{"minimum":16846.99,"maximum":16872.77,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16846.99,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16872.77,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","code_information":[{"code":"517","type":"MS-DRG"}],"standard_charges":[{"minimum":12500.62,"maximum":12500.62,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12500.62,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","code_information":[{"code":"521","type":"MS-DRG"}],"standard_charges":[{"minimum":24409.16,"maximum":54519.1,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24409.16,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":54519.1,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","code_information":[{"code":"522","type":"MS-DRG"}],"standard_charges":[{"minimum":17352.35,"maximum":19396.66,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17598.14,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19396.66,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17352.35,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fractures Of Hip And Pelvis With Mcc","code_information":[{"code":"535","type":"MS-DRG"}],"standard_charges":[{"minimum":11170.61,"maximum":11170.61,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11170.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"minimum":2928.51,"maximum":6945.26,"setting":"inpatient","payers_information":[{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2928.51,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6783.92,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5191.53,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6945.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","code_information":[{"code":"537","type":"MS-DRG"}],"standard_charges":[{"minimum":6168.19,"maximum":6168.19,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6168.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","code_information":[{"code":"538","type":"MS-DRG"}],"standard_charges":[{"minimum":4024.12,"maximum":4024.12,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4024.12,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Osteomyelitis With Mcc","code_information":[{"code":"539","type":"MS-DRG"}],"standard_charges":[{"minimum":13316.08,"maximum":13316.08,"setting":"inpatient","payers_information":[{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13316.08,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","code_information":[{"code":"542","type":"MS-DRG"}],"standard_charges":[{"minimum":9334.33,"maximum":15053.46,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9334.33,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15053.46,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11941.59,"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":6015.54,"maximum":19341.93,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6015.54,"methodology":"other"},{"payer_name":"Medicare Advantage","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":7796.67,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":9096.6,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":19341.93,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","code_information":[{"code":"544","type":"MS-DRG"}],"standard_charges":[{"minimum":6150.57,"maximum":6150.57,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6150.57,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Connective Tissue Disorders With Cc","code_information":[{"code":"546","type":"MS-DRG"}],"standard_charges":[{"minimum":16013.35,"maximum":16013.35,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16013.35,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Septic Arthritis With Cc","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"minimum":10092.11,"maximum":10092.11,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10092.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Medical Back Problems With Mcc","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"minimum":12690.87,"maximum":22721.84,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":22721.84,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12690.87,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14206.87,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":13983.67,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"minimum":2262.4,"maximum":13314.48,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2262.4,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":13314.48,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8071.33,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8056.89,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8030.14,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Bone Diseases And Arthropathies With Mcc","code_information":[{"code":"553","type":"MS-DRG"}],"standard_charges":[{"minimum":10937.1,"maximum":10937.1,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10937.1,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Bone Diseases And Arthropathies Without Mcc","code_information":[{"code":"554","type":"MS-DRG"}],"standard_charges":[{"minimum":6948.58,"maximum":9615.96,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6948.58,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7021.99,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9615.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"555","type":"MS-DRG"}],"standard_charges":[{"minimum":6168.19,"maximum":19124.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19124.0,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6168.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","code_information":[{"code":"556","type":"MS-DRG"}],"standard_charges":[{"minimum":6168.19,"maximum":6832.62,"setting":"inpatient","payers_information":[{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6832.62,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6168.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Tendonitis, Myositis And Bursitis With Mcc","code_information":[{"code":"557","type":"MS-DRG"}],"standard_charges":[{"minimum":13010.6,"maximum":13010.6,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13010.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Tendonitis, Myositis And Bursitis Without Mcc","code_information":[{"code":"558","type":"MS-DRG"}],"standard_charges":[{"minimum":7266.54,"maximum":13850.13,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":10653.87,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":13850.13,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7266.54,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11524.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"minimum":15545.58,"maximum":15545.58,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15545.58,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"minimum":9536.04,"maximum":9536.04,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9536.04,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"minimum":12200.4,"maximum":12289.6,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12289.6,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12200.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","code_information":[{"code":"563","type":"MS-DRG"}],"standard_charges":[{"minimum":7476.13,"maximum":15211.95,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7476.13,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":15211.95,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":14679.77,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7517.76,"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":13079.41,"maximum":20209.56,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13079.41,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13141.26,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20209.56,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"minimum":8539.48,"maximum":13507.31,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":13507.31,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8539.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Skin Debridement With Cc","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"minimum":13252.49,"maximum":20685.61,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":13252.49,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20685.61,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14054.07,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","code_information":[{"code":"580","type":"MS-DRG"}],"standard_charges":[{"minimum":21880.88,"maximum":29226.0,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":21880.88,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29226.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","code_information":[{"code":"581","type":"MS-DRG"}],"standard_charges":[{"minimum":12085.22,"maximum":12085.22,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12085.22,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Mastectomy For Malignancy Without Cc/Mcc","code_information":[{"code":"583","type":"MS-DRG"}],"standard_charges":[{"minimum":13789.44,"maximum":13789.44,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13789.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Skin Disorders With Mcc","code_information":[{"code":"595","type":"MS-DRG"}],"standard_charges":[{"minimum":17745.54,"maximum":17745.54,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":17745.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Malignant Breast Disorders With Cc","code_information":[{"code":"598","type":"MS-DRG"}],"standard_charges":[{"minimum":9036.44,"maximum":9036.44,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9036.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cellulitis With Mcc","code_information":[{"code":"602","type":"MS-DRG"}],"standard_charges":[{"minimum":12303.81,"maximum":12303.81,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12303.81,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"minimum":4828.18,"maximum":23254.42,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7357.72,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7375.86,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":23254.42,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":17228.36,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21574.4,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4828.18,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7376.26,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6398.92,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6398.92,"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":12441.99,"maximum":12441.99,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12441.99,"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":7696.4,"maximum":7768.16,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7768.16,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7696.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Minor Skin Disorders With Mcc","code_information":[{"code":"606","type":"MS-DRG"}],"standard_charges":[{"minimum":12556.93,"maximum":12556.93,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":12556.93,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"616","type":"MS-DRG"}],"standard_charges":[{"minimum":32367.46,"maximum":32367.46,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32367.46,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"617","type":"MS-DRG"}],"standard_charges":[{"minimum":13834.08,"maximum":29452.6,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29452.6,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16129.24,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":13834.08,"methodology":"other"}],"billing_class":"facility"}]},{"description":"O.R. Procedures For Obesity With Cc","code_information":[{"code":"620","type":"MS-DRG"}],"standard_charges":[{"minimum":12180.86,"maximum":12180.86,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12180.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"O.R. Procedures For Obesity Without Cc/Mcc","code_information":[{"code":"621","type":"MS-DRG"}],"standard_charges":[{"minimum":10836.28,"maximum":33015.31,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":33015.31,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19952.28,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10836.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"622","type":"MS-DRG"}],"standard_charges":[{"minimum":31154.59,"maximum":31154.59,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":31154.59,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","code_information":[{"code":"627","type":"MS-DRG"}],"standard_charges":[{"minimum":9010.3,"maximum":9010.3,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9010.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","code_information":[{"code":"628","type":"MS-DRG"}],"standard_charges":[{"minimum":31400.31,"maximum":31400.31,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":31400.31,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","code_information":[{"code":"629","type":"MS-DRG"}],"standard_charges":[{"minimum":18752.72,"maximum":18871.11,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18871.11,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18752.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"minimum":6130.53,"maximum":19379.97,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9223.29,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6130.53,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19379.97,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes With Cc","code_information":[{"code":"638","type":"MS-DRG"}],"standard_charges":[{"minimum":3044.21,"maximum":24578.69,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7656.09,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":12492.65,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":24578.69,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3044.21,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9223.29,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7713.73,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6116.36,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7636.29,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6116.36,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Diabetes Without Cc/Mcc","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"minimum":11045.51,"maximum":11045.51,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11045.51,"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":9213.36,"maximum":18624.58,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9213.36,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9480.34,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":11391.37,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":18624.58,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9470.06,"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":1471.0,"maximum":10515.2,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6514.68,"methodology":"other"},{"payer_name":"Aetna","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":1471.0,"methodology":"other"},{"payer_name":"Luminare","plan_name":"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":2842.0,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6543.83,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":6700.04,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8158.11,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5008.08,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10515.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Endocrine Disorders With Mcc","code_information":[{"code":"643","type":"MS-DRG"}],"standard_charges":[{"minimum":13837.59,"maximum":14207.23,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13837.59,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13880.9,"methodology":"other"},{"payer_name":"Medicare Advantage","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":14207.23,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"minimum":8654.2,"maximum":19747.11,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":19747.11,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8654.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"minimum":6521.23,"maximum":6521.23,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6521.23,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Cc","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"minimum":15342.05,"maximum":36153.4,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":36153.4,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15342.05,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"minimum":21543.48,"maximum":21674.86,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21674.86,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":21543.48,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Cc","code_information":[{"code":"660","type":"MS-DRG"}],"standard_charges":[{"minimum":9622.46,"maximum":22600.18,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10928.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":22600.18,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":17720.77,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10202.31,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9622.46,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":11489.7,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11159.86,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10421.69,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"minimum":4924.48,"maximum":15696.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8582.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":13632.5,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":15696.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":4924.48,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14424.31,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4926.9,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13900.38,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11029.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Procedures With Mcc","code_information":[{"code":"673","type":"MS-DRG"}],"standard_charges":[{"minimum":23494.3,"maximum":35085.81,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":34918.15,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":35085.81,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23494.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Procedures With Cc","code_information":[{"code":"674","type":"MS-DRG"}],"standard_charges":[{"minimum":19364.34,"maximum":19364.34,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19364.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","code_information":[{"code":"675","type":"MS-DRG"}],"standard_charges":[{"minimum":13050.98,"maximum":13050.98,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13050.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"minimum":1975.0,"maximum":12883.07,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1975.0,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8528.07,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11434.36,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":12883.07,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12844.68,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"minimum":4262.5,"maximum":7621.79,"setting":"inpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":4262.5,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7400.68,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5844.74,"methodology":"other"},{"payer_name":"Medicare Advantage","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":7621.79,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7413.01,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Renal Failure Without Cc/Mcc","code_information":[{"code":"684","type":"MS-DRG"}],"standard_charges":[{"minimum":2842.0,"maximum":5120.86,"setting":"inpatient","payers_information":[{"payer_name":"Luminare","plan_name":"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":2842.0,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5120.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Neoplasms With Mcc","code_information":[{"code":"686","type":"MS-DRG"}],"standard_charges":[{"minimum":15791.79,"maximum":15791.79,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15791.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"minimum":9743.52,"maximum":9800.68,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9800.68,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9743.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"minimum":4496.27,"maximum":6722.26,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6719.24,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4496.27,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6722.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Urinary Stones Without Mcc","code_information":[{"code":"694","type":"MS-DRG"}],"standard_charges":[{"minimum":2904.0,"maximum":10525.03,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":10525.03,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9141.29,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6576.47,"methodology":"other"},{"payer_name":"United Healthcare","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":2904.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":6254.37,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4926.9,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Mcc","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"minimum":13991.45,"maximum":20506.53,"setting":"inpatient","payers_information":[{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13991.45,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14076.71,"methodology":"other"},{"payer_name":"Medicare Advantage","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":14412.72,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20506.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"minimum":8041.92,"maximum":8041.92,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8041.92,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","code_information":[{"code":"700","type":"MS-DRG"}],"standard_charges":[{"minimum":5847.0,"maximum":5847.0,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5847.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Male Pelvic Procedures Without Cc/Mcc","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"minimum":33642.01,"maximum":38052.8,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":33642.01,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":38052.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","code_information":[{"code":"718","type":"MS-DRG"}],"standard_charges":[{"minimum":8823.98,"maximum":8823.98,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8823.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Malignancy, Male Reproductive System With Cc","code_information":[{"code":"723","type":"MS-DRG"}],"standard_charges":[{"minimum":9436.36,"maximum":9436.36,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9436.36,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Benign Prostatic Hypertrophy Without Mcc","code_information":[{"code":"726","type":"MS-DRG"}],"standard_charges":[{"minimum":6266.63,"maximum":6266.63,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6266.63,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inflammation Of The Male Reproductive System With Mcc","code_information":[{"code":"727","type":"MS-DRG"}],"standard_charges":[{"minimum":17604.38,"maximum":17604.38,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":17604.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Male Reproductive System Diagnoses With Cc/Mcc","code_information":[{"code":"729","type":"MS-DRG"}],"standard_charges":[{"minimum":12004.62,"maximum":12004.62,"setting":"inpatient","payers_information":[{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12004.62,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","code_information":[{"code":"742","type":"MS-DRG"}],"standard_charges":[{"minimum":2180.76,"maximum":5464.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5464.0,"methodology":"other"},{"payer_name":"Tufts 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":2180.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","code_information":[{"code":"743","type":"MS-DRG"}],"standard_charges":[{"minimum":9741.33,"maximum":20336.72,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":20336.72,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12542.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":9741.33,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Malignancy, Female Reproductive System With Mcc","code_information":[{"code":"754","type":"MS-DRG"}],"standard_charges":[{"minimum":4807.98,"maximum":4807.98,"setting":"inpatient","payers_information":[{"payer_name":"Tufts 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":4807.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Infections, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"759","type":"MS-DRG"}],"standard_charges":[{"minimum":14283.22,"maximum":14283.22,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":14283.22,"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":1400.0,"maximum":3044.21,"setting":"inpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":3044.21,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1400.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","code_information":[{"code":"768","type":"MS-DRG"}],"standard_charges":[{"minimum":8446.53,"maximum":14533.54,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10212.8,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":10242.17,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":11179.57,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":14533.54,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":8572.08,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11869.86,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11869.86,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8446.53,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10242.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","code_information":[{"code":"776","type":"MS-DRG"}],"standard_charges":[{"minimum":5687.0,"maximum":9090.57,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":9090.57,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":7783.05,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":6103.02,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7851.4,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":5687.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Abortion Without D&C","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"minimum":9804.5,"maximum":9804.5,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":9804.5,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cesarean Section With Sterilization With Mcc","code_information":[{"code":"783","type":"MS-DRG"}],"standard_charges":[{"minimum":22077.85,"maximum":22077.85,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":22077.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cesarean Section With Sterilization With Cc","code_information":[{"code":"784","type":"MS-DRG"}],"standard_charges":[{"minimum":14623.28,"maximum":22077.85,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":16982.84,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":22077.85,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14623.28,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cesarean Section With Sterilization Without Cc/Mcc","code_information":[{"code":"785","type":"MS-DRG"}],"standard_charges":[{"minimum":8140.69,"maximum":19114.44,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":9049.01,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":19114.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":8140.69,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12969.01,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cesarean Section Without Sterilization With Mcc","code_information":[{"code":"786","type":"MS-DRG"}],"standard_charges":[{"minimum":13280.0,"maximum":28879.07,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13764.8,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":17575.11,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":28879.07,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14723.94,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19044.74,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14020.85,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13280.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20589.35,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cesarean Section Without Sterilization With Cc","code_information":[{"code":"787","type":"MS-DRG"}],"standard_charges":[{"minimum":5155.2,"maximum":22847.8,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":5155.2,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9491.2,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":17575.11,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":22847.8,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":11777.19,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16079.09,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16079.09,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11330.75,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":9176.69,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12099.83,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8874.09,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13280.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":13280.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14872.83,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11330.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cesarean Section Without Sterilization Without Cc/Mcc","code_information":[{"code":"788","type":"MS-DRG"}],"standard_charges":[{"minimum":6119.84,"maximum":18756.32,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6119.84,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":14427.84,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":18756.32,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":10854.27,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9176.69,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9045.21,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8874.09,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":12969.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14020.85,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14623.28,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9699.09,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":13280.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13280.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":13280.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":7559.67,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8849.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Neonates, Died Or Transferred To Another Acute Care Facility","code_information":[{"code":"789","type":"MS-DRG"}],"standard_charges":[{"minimum":1962.28,"maximum":47257.76,"setting":"inpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":1962.28,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":47257.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","code_information":[{"code":"790","type":"MS-DRG"}],"standard_charges":[{"minimum":14073.36,"maximum":58293.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":58293.0,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":26442.14,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14073.36,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Prematurity With Major Problems","code_information":[{"code":"791","type":"MS-DRG"}],"standard_charges":[{"minimum":1838.6,"maximum":30171.44,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1838.6,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":5196.57,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30171.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Prematurity Without Major Problems","code_information":[{"code":"792","type":"MS-DRG"}],"standard_charges":[{"minimum":2686.78,"maximum":53396.18,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":17241.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23749.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":5823.93,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":34858.95,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":53396.18,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3061.1,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2686.78,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5334.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12824.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3802.31,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Full Term Neonate With Major Problems","code_information":[{"code":"793","type":"MS-DRG"}],"standard_charges":[{"minimum":1557.0,"maximum":6644.46,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":1557.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4252.99,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6644.46,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Neonate With Other Significant Problems","code_information":[{"code":"794","type":"MS-DRG"}],"standard_charges":[{"minimum":2161.42,"maximum":7112.0,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":2568.43,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2553.2,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2161.42,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":3061.1,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3061.1,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4252.99,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2686.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2332.07,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5334.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":7112.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4252.99,"methodology":"other"},{"payer_name":"United Healthcare","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":3556.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Normal Newborn","code_information":[{"code":"795","type":"MS-DRG"}],"standard_charges":[{"minimum":1840.0,"maximum":5492.72,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2553.2,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":3556.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2026.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5492.72,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":3061.1,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3061.1,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3061.1,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2109.95,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1887.08,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3556.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":1840.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3061.1,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Cc","code_information":[{"code":"797","type":"MS-DRG"}],"standard_charges":[{"minimum":13303.27,"maximum":13303.27,"setting":"inpatient","payers_information":[{"payer_name":"United Healthcare","plan_name":"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":13303.27,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"minimum":8563.15,"maximum":8563.15,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8563.15,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Mcc","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"minimum":7460.06,"maximum":34953.58,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":10212.8,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15911.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":34953.58,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":12653.43,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11759.69,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10242.17,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9551.49,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7472.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7460.06,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":10684.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8620.02,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Cc","code_information":[{"code":"806","type":"MS-DRG"}],"standard_charges":[{"minimum":5160.0,"maximum":12653.43,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":5160.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10569.6,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":9733.34,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":12653.43,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":8680.62,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6030.14,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7460.06,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":10242.17,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10242.17,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10242.17,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8579.07,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7460.06,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10684.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":10684.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10242.17,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":5371.4,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7460.06,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","code_information":[{"code":"807","type":"MS-DRG"}],"standard_charges":[{"minimum":1152.69,"maximum":11080.7,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","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":3736.8,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7864.8,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8523.56,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":9733.34,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":11080.7,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":5787.08,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9176.69,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6650.63,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1152.69,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9267.31,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10242.17,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7460.07,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5369.71,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7599.2,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10684.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7648.23,"methodology":"other"},{"payer_name":"Tufts 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":9176.69,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":10684.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10684.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":10684.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9267.31,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":5050.27,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"808","type":"MS-DRG"}],"standard_charges":[{"minimum":7238.58,"maximum":18862.74,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7238.58,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":18862.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"810","type":"MS-DRG"}],"standard_charges":[{"minimum":8004.37,"maximum":8004.37,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8004.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Red Blood Cell Disorders With Mcc","code_information":[{"code":"811","type":"MS-DRG"}],"standard_charges":[{"minimum":6271.0,"maximum":14157.59,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14157.59,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11814.72,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":12063.32,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6271.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"minimum":1421.0,"maximum":8983.78,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7686.14,"methodology":"other"},{"payer_name":"Aetna","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":1421.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8983.78,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7706.84,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7728.83,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"minimum":12996.35,"maximum":20786.65,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":20786.65,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12996.35,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Reticuloendothelial And Immunity Disorders With Cc","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"minimum":8555.79,"maximum":15128.0,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":15128.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8555.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Mcc","code_information":[{"code":"817","type":"MS-DRG"}],"standard_charges":[{"minimum":5271.32,"maximum":5271.32,"setting":"inpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":5271.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"minimum":37323.09,"maximum":37323.09,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":37323.09,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","code_information":[{"code":"826","type":"MS-DRG"}],"standard_charges":[{"minimum":40025.38,"maximum":40025.38,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":40025.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"minimum":2533.6,"maximum":10092.9,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":10092.9,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2533.6,"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":3879.71,"maximum":10092.9,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":10092.9,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3879.71,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4008.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","code_information":[{"code":"833","type":"MS-DRG"}],"standard_charges":[{"minimum":5768.84,"maximum":5768.84,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":5768.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Leukemia With Mcc","code_information":[{"code":"834","type":"MS-DRG"}],"standard_charges":[{"minimum":98152.29,"maximum":98152.29,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":98152.29,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"minimum":13164.55,"maximum":13164.55,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13164.55,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","code_information":[{"code":"844","type":"MS-DRG"}],"standard_charges":[{"minimum":10041.85,"maximum":10041.85,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10041.85,"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":21427.27,"maximum":102320.96,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":54373.58,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":21427.27,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":38070.63,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":102320.96,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":39265.67,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":41642.48,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":43197.77,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","code_information":[{"code":"854","type":"MS-DRG"}],"standard_charges":[{"minimum":5834.29,"maximum":43144.02,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":43144.02,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16765.74,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5834.29,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","code_information":[{"code":"856","type":"MS-DRG"}],"standard_charges":[{"minimum":28748.22,"maximum":28748.22,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28748.22,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","code_information":[{"code":"857","type":"MS-DRG"}],"standard_charges":[{"minimum":18247.2,"maximum":18247.2,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18247.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Postoperative And Post-Traumatic Infections With Mcc","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"minimum":1894.25,"maximum":15398.19,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":1894.25,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15398.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Postoperative And Post-Traumatic Infections Without Mcc","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"minimum":8406.3,"maximum":10422.48,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10422.48,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8406.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Viral Illness With Mcc","code_information":[{"code":"865","type":"MS-DRG"}],"standard_charges":[{"minimum":9969.14,"maximum":9969.14,"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9969.14,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"minimum":6490.0,"maximum":6514.91,"setting":"inpatient","payers_information":[{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6514.91,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":6490.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Septicemia Or Severe Sepsis With Mv >96 Hours","code_information":[{"code":"870","type":"MS-DRG"}],"standard_charges":[{"minimum":22309.85,"maximum":57967.98,"setting":"inpatient","payers_information":[{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":57967.98,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22309.85,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":56657.85,"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":4773.16,"maximum":31496.3,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6676.17,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13364.07,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8196.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":24227.76,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":31496.3,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":11514.04,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14626.59,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16335.76,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":14076.19,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":26042.98,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10661.99,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14832.24,"methodology":"other"},{"payer_name":"Medicare Advantage","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":13469.65,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":16823.83,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4773.16,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13334.69,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":25084.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16335.76,"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":2732.0,"maximum":21427.27,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8586.4,"methodology":"other"},{"payer_name":"Aetna","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":11312.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2732.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12816.33,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":16482.4,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":21427.27,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":12206.04,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8616.37,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8618.77,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8583.73,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8317.92,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8595.62,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8908.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Acute Adjustment Reaction And Psychosocial Dysfunction","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"minimum":6385.32,"maximum":6385.32,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6385.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Neuroses Except Depressive","code_information":[{"code":"882","type":"MS-DRG"}],"standard_charges":[{"minimum":1765.81,"maximum":1765.81,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1765.81,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"minimum":8960.6,"maximum":11856.02,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11856.02,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8960.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Psychoses","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"minimum":11869.98,"maximum":127839.05,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11869.98,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":127839.05,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":46157.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Alcohol, Drug Abuse Or Dependence, Left Ama","code_information":[{"code":"894","type":"MS-DRG"}],"standard_charges":[{"minimum":2683.7,"maximum":12682.0,"setting":"inpatient","payers_information":[{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3933.62,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2683.7,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5227.21,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7534.58,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":12682.0,"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":1900.0,"maximum":63449.55,"setting":"inpatient","payers_information":[{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14830.92,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":63449.55,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10016.67,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10806.32,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1900.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":23684.4,"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":6660.51,"maximum":16770.73,"setting":"inpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7344.9,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7371.61,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":16770.73,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":10901.19,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15363.45,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10524.47,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7391.75,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6677.24,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6660.51,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7098.74,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6660.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other O.R. Procedures For Injuries With Cc","code_information":[{"code":"908","type":"MS-DRG"}],"standard_charges":[{"minimum":15292.85,"maximum":15292.85,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15292.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other O.R. Procedures For Injuries Without Cc/Mcc","code_information":[{"code":"909","type":"MS-DRG"}],"standard_charges":[{"minimum":12542.0,"maximum":12542.0,"setting":"inpatient","payers_information":[{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12542.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Traumatic Injury Without Mcc","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"minimum":7707.03,"maximum":7707.03,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7707.03,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Allergic Reactions With Mcc","code_information":[{"code":"915","type":"MS-DRG"}],"standard_charges":[{"minimum":26685.61,"maximum":26685.61,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":26685.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Allergic Reactions Without Mcc","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"minimum":5274.21,"maximum":5274.21,"setting":"inpatient","payers_information":[{"payer_name":"Wellpoint Gic","plan_name":"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":5274.21,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Poisoning And Toxic Effects Of Drugs With Mcc","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"minimum":16405.72,"maximum":38297.52,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":17657.75,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":38297.52,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16405.73,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16405.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"minimum":16560.45,"maximum":16560.45,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":16560.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Complications Of Treatment With Mcc","code_information":[{"code":"919","type":"MS-DRG"}],"standard_charges":[{"minimum":15179.24,"maximum":81735.66,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15304.38,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":81735.66,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15188.66,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15179.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Complications Of Treatment With Cc","code_information":[{"code":"920","type":"MS-DRG"}],"standard_charges":[{"minimum":8049.86,"maximum":8540.29,"setting":"inpatient","payers_information":[{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8049.86,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8540.29,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Complications Of Treatment Without Cc/Mcc","code_information":[{"code":"921","type":"MS-DRG"}],"standard_charges":[{"minimum":12318.18,"maximum":12329.42,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":12318.18,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":12329.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","code_information":[{"code":"922","type":"MS-DRG"}],"standard_charges":[{"minimum":14180.52,"maximum":14180.52,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14180.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Factors Influencing Health Status","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"minimum":4720.64,"maximum":4720.64,"setting":"inpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4720.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","code_information":[{"code":"956","type":"MS-DRG"}],"standard_charges":[{"minimum":32043.34,"maximum":32043.34,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":32043.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"minimum":20379.1,"maximum":40761.85,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20379.1,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":38212.18,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":40761.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"983","type":"MS-DRG"}],"standard_charges":[{"minimum":32039.44,"maximum":32039.44,"setting":"inpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":32039.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"987","type":"MS-DRG"}],"standard_charges":[{"minimum":29337.26,"maximum":29337.26,"setting":"inpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29337.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Ungroupable","code_information":[{"code":"999","type":"MS-DRG"}],"standard_charges":[{"minimum":2984.56,"maximum":33015.31,"setting":"inpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8196.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":33015.31,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2984.56,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10822.46,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":11939.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Ketorolac tromethamine inj","code_information":[{"code":"0764","type":"APC"}],"standard_charges":[{"minimum":30.09,"maximum":14773.5,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3072.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30.09,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14773.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":1660.54,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Inj, methylpred acetate 1 mg","code_information":[{"code":"0790","type":"APC"}],"standard_charges":[{"minimum":65.87,"maximum":65.87,"setting":"outpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":65.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Penicillin g benzathine inj","code_information":[{"code":"1829","type":"APC"}],"standard_charges":[{"minimum":616.59,"maximum":616.59,"setting":"outpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":616.59,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Clinic Visits and Related Services","code_information":[{"code":"5012","type":"APC"}],"standard_charges":[{"minimum":56.79,"maximum":446.58,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.4,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":153.04,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.39,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.97,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":419.35,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":56.79,"methodology":"other"},{"payer_name":"Medicare Advantage","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":141.97,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":141.97,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.39,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":150.59,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"minimum":96.9,"maximum":1758.74,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":96.9,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":114.75,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":101.75,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":480.0,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":149.34,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":439.89,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":149.34,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":403.48,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1758.74,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":640.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"minimum":149.34,"maximum":502.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":177.33,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":175.64,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":186.72,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":218.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":502.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":480.0,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":149.34,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":175.64,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":225.05,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":419.06,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"minimum":100.0,"maximum":2128.58,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":307.58,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":324.74,"methodology":"other"},{"payer_name":"Aetna","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":795.52,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":698.13,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":621.42,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":545.05,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":325.38,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":396.74,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":351.15,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1184.57,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":995.05,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":919.36,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":306.42,"methodology":"other"},{"payer_name":"Empire Nyship","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.0,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":221.39,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":462.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":480.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":606.89,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":250.74,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":306.42,"methodology":"other"},{"payer_name":"Medicare Advantage","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":306.42,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":323.56,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":2128.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":747.75,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":261.67,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":902.97,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":307.37,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":311.4,"methodology":"other"},{"payer_name":"Tufts 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":824.47,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1399.14,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1015.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":480.0,"methodology":"other"},{"payer_name":"United Healthcare","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":1265.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":935.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":441.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":819.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":311.4,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":396.51,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":250.74,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":387.06,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"minimum":100.0,"maximum":4491.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":521.71,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":728.43,"methodology":"other"},{"payer_name":"Aetna","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":1043.69,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":1163.95,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":2001.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":780.79,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":960.33,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":824.69,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Indemnity","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":717.69,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":733.43,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":754.45,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1234.32,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1268.08,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1234.32,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":595.58,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":475.67,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":403.87,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"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":1419.31,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1113.32,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":865.22,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":673.9,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":735.4,"methodology":"other"},{"payer_name":"Healthpartners","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1184.57,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":379.74,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"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":695.29,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":621.87,"methodology":"other"},{"payer_name":"Medicare Advantage","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":807.9,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":729.4,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2045.46,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":923.7,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":990.47,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":495.75,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":364.02,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1323.41,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":593.52,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":631.98,"methodology":"other"},{"payer_name":"Tufts 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":1182.89,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Supplement","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4491.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":2011.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2040.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":735.4,"methodology":"other"},{"payer_name":"United Healthcare","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":1952.6,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":2457.43,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":516.22,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":2323.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":483.4,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":931.42,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":378.6,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":604.05,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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"}],"billing_class":"facility"}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"minimum":90.0,"maximum":9859.14,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1130.62,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1234.13,"methodology":"other"},{"payer_name":"Aetna","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":650.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":2091.77,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"Anthem","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9859.14,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2075.47,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2952.83,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1306.36,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1757.57,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1581.32,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Indemnity","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4810.84,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1322.39,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1234.32,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2351.4,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1234.32,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1109.77,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":571.45,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"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":1522.05,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":90.0,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1290.35,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1236.11,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1061.53,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":498.03,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1102.82,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1453.0,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1244.79,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":1944.53,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":535.39,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":736.43,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2108.65,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1015.66,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1265.04,"methodology":"other"},{"payer_name":"Tufts 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":1615.52,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2904.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1247.01,"methodology":"other"},{"payer_name":"United Healthcare","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":2904.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2904.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1120.76,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1631.2,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":507.96,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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"}],"billing_class":"facility"}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"minimum":425.93,"maximum":6191.18,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2943.19,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2934.7,"methodology":"other"},{"payer_name":"Aetna","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":6191.18,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":456.44,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":5534.32,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1566.57,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2054.25,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1234.32,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2081.88,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":669.4,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1130.07,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2288.15,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1254.09,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":550.13,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1502.16,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":2129.23,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":472.42,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1014.38,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":425.93,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1626.92,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2060.48,"methodology":"other"},{"payer_name":"Tufts 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":500.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1056.35,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2904.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":495.27,"methodology":"other"},{"payer_name":"United Healthcare","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":2904.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1360.45,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":5362.01,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1146.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"minimum":218.5,"maximum":2581.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":218.5,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2581.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":548.04,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":257.47,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":290.36,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":805.79,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":773.31,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":382.78,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":683.9,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":654.25,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":748.04,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":595.78,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":271.79,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":544.61,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":488.24,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":355.52,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":897.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1054.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":355.53,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":480.25,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":525.78,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"minimum":427.3,"maximum":1373.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":464.99,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":427.3,"methodology":"other"},{"payer_name":"Aetna","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":1373.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1373.0,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":480.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":516.85,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":458.3,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1234.32,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":756.0,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":428.24,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":583.45,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":829.11,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":650.15,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":712.96,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":469.96,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":570.21,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":664.26,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":779.35,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":567.89,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":570.21,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":829.36,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":464.99,"methodology":"other"},{"payer_name":"United Healthcare","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":756.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":1113.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":583.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"minimum":100.0,"maximum":1547.63,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":672.66,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1547.63,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":704.62,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":122.02,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":999.58,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":731.29,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":813.17,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":583.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Skin Procedures","code_information":[{"code":"5054","type":"APC"}],"standard_charges":[{"minimum":50.0,"maximum":3916.99,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2136.78,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3390.3,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3301.93,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3516.14,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2197.8,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":3916.99,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2136.27,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2130.88,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Skin Procedures","code_information":[{"code":"5055","type":"APC"}],"standard_charges":[{"minimum":4180.6,"maximum":4278.06,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4278.06,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4180.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Hyperbaric Oxygen","code_information":[{"code":"5061","type":"APC"}],"standard_charges":[{"minimum":592.33,"maximum":1892.0,"setting":"outpatient","payers_information":[{"payer_name":"Anthem","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":753.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1892.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":639.75,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1038.75,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":596.1,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":644.56,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":593.68,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1038.76,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":592.33,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"minimum":124.95,"maximum":3354.24,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":918.45,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":819.45,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2581.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1127.47,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1235.46,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":848.67,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1879.13,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1022.36,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":423.35,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":2106.55,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1709.88,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1315.1,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":812.4,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":897.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":212.71,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":124.95,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":752.54,"methodology":"other"},{"payer_name":"Tufts 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":490.17,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":3354.24,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2559.7,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1315.1,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":2381.7,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1019.46,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":759.02,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"minimum":117.87,"maximum":8732.81,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1858.98,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1837.22,"methodology":"other"},{"payer_name":"Aetna","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":8732.81,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2581.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2635.38,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2437.29,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1889.43,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2113.53,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1889.41,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1909.77,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1368.34,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":3430.43,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3850.7,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4027.22,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":117.87,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1843.82,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1741.2,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":274.99,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1843.72,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4643.28,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3277.15,"methodology":"other"},{"payer_name":"United Healthcare","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":5384.87,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":7266.23,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2796.98,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":4685.97,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2036.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"minimum":270.0,"maximum":7866.88,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2413.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3918.49,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2507.81,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":5453.08,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7866.88,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3051.65,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":270.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":6435.09,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3039.25,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"minimum":2581.0,"maximum":8389.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4464.05,"methodology":"other"},{"payer_name":"Aetna","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":2581.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":5261.15,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":5990.6,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2599.06,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7887.18,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7153.69,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5868.83,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4093.66,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6982.32,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8389.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4493.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5092","type":"APC"}],"standard_charges":[{"minimum":125.0,"maximum":18450.88,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18450.88,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":12546.03,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":13842.02,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7786.67,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":193.3,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7237.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":188.92,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7597.54,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":13084.5,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5574.98,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":125.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5093","type":"APC"}],"standard_charges":[{"minimum":10090.48,"maximum":39243.37,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":16321.44,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10115.32,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15827.34,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10090.48,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":39243.37,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5094","type":"APC"}],"standard_charges":[{"minimum":929.65,"maximum":929.65,"setting":"outpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":929.65,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Strapping and Cast Application","code_information":[{"code":"5101","type":"APC"}],"standard_charges":[{"minimum":196.44,"maximum":961.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":309.94,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":560.39,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":221.53,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":196.44,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":311.19,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":762.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":762.01,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":244.63,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":333.62,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":311.19,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":333.63,"methodology":"other"},{"payer_name":"United Healthcare","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":961.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":961.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Musculoskeletal Procedures","code_information":[{"code":"5111","type":"APC"}],"standard_charges":[{"minimum":253.26,"maximum":3129.0,"setting":"outpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":2664.06,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":253.26,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3129.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":4699.08,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1726.46,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1868.47,"methodology":"other"},{"payer_name":"Aetna","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":2748.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2413.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2092.72,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2161.21,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2413.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2514.81,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2564.96,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":621.42,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1589.83,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1726.07,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1870.17,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1726.07,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2847.68,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1864.07,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":4597.42,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4699.08,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2683.16,"methodology":"other"},{"payer_name":"United Healthcare","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":3812.51,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":685.56,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":2779.93,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2368.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"minimum":445.0,"maximum":12418.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3470.01,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":445.0,"methodology":"other"},{"payer_name":"Aetna","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":5555.43,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3469.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":4316.91,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3886.22,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2752.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4330.61,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2281.65,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":770.63,"methodology":"other"},{"payer_name":"Empire Nyship","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4316.91,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3815.32,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":4887.29,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5359.49,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5359.49,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3476.24,"methodology":"other"},{"payer_name":"Medicare Advantage","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":3791.52,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":3476.24,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12418.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4563.41,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6778.64,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3464.1,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":6153.67,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4613.28,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1360.36,"methodology":"other"},{"payer_name":"United Healthcare","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":7238.19,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":6235.69,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":3052.39,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3281.86,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"minimum":250.0,"maximum":18983.05,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8321.84,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8320.94,"methodology":"other"},{"payer_name":"Aetna","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":2671.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13305.41,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":9871.82,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":10788.71,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3854.07,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2914.2,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":13061.98,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13061.98,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15018.12,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7683.18,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":8538.2,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":18983.05,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8321.34,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8538.2,"methodology":"other"},{"payer_name":"Tufts 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":250.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":12081.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16691.01,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":692.68,"methodology":"other"},{"payer_name":"United Healthcare","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":18121.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":18121.5,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":7268.8,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4563.41,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"minimum":410.0,"maximum":20749.6,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":410.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14304.84,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":18633.44,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":16738.22,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":20749.6,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20578.82,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":18922.61,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19360.71,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20273.51,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14330.48,"methodology":"other"},{"payer_name":"Medicare Advantage","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":14244.32,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":14355.3,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6448.49,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14299.94,"methodology":"other"},{"payer_name":"Tufts 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":17121.83,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":17716.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20545.27,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":938.08,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":18763.12,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4634.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 6 Musculoskeletal Procedures","code_information":[{"code":"5116","type":"APC"}],"standard_charges":[{"minimum":102.54,"maximum":21600.36,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":102.54,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":15614.75,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18537.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18907.33,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20158.41,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":21600.36,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20050.94,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":21141.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Airway Endoscopy","code_information":[{"code":"5153","type":"APC"}],"standard_charges":[{"minimum":372.21,"maximum":3532.84,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3532.84,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":372.21,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1822.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Airway Endoscopy","code_information":[{"code":"5154","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":5230.31,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":5230.31,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4021.8,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Airway Endoscopy","code_information":[{"code":"5155","type":"APC"}],"standard_charges":[{"minimum":2844.0,"maximum":28661.63,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2844.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":20924.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":17075.16,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":28661.63,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7350.5,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7326.02,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 ENT Procedures","code_information":[{"code":"5163","type":"APC"}],"standard_charges":[{"minimum":984.51,"maximum":5729.15,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","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":2497.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2413.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3157.28,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2953.19,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5729.15,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3919.8,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3919.8,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":984.51,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1730.96,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3871.04,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2613.2,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 ENT Procedures","code_information":[{"code":"5164","type":"APC"}],"standard_charges":[{"minimum":1525.5,"maximum":10749.81,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2748.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":7343.45,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3458.06,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3698.73,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8842.04,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":10749.81,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4262.38,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4674.2,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3457.74,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1525.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7248.7,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4597.46,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":4456.07,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":9286.1,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2149.89,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3361.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 ENT Procedures","code_information":[{"code":"5165","type":"APC"}],"standard_charges":[{"minimum":1199.75,"maximum":14994.07,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6263.73,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2135.86,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3634.88,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1199.75,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4959.37,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6289.3,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14994.07,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8045.31,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6885.1,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":7682.86,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4571.52,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Vascular Procedures","code_information":[{"code":"5181","type":"APC"}],"standard_charges":[{"minimum":471.58,"maximum":1602.35,"setting":"outpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1570.73,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":674.67,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":471.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1602.35,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":823.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Vascular Procedures","code_information":[{"code":"5182","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":7386.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1807.91,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5109.18,"methodology":"other"},{"payer_name":"Anthem","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5466.66,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":5268.8,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1530.42,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1260.54,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1829.77,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1686.62,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1283.42,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4537.13,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4015.4,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1719.98,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1815.28,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2054.41,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1714.79,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7386.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1822.35,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1925.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"minimum":1968.79,"maximum":8133.93,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3670.6,"methodology":"other"},{"payer_name":"Aetna","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":5423.31,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":4366.46,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3854.45,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1968.79,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8133.93,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6061.42,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3423.23,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":3678.04,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2581.0,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7061.61,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3665.59,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3678.04,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":7288.21,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":7492.87,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2272.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Vascular Procedures","code_information":[{"code":"5184","type":"APC"}],"standard_charges":[{"minimum":5877.8,"maximum":5901.79,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5901.79,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5877.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Endovascular Procedures","code_information":[{"code":"5192","type":"APC"}],"standard_charges":[{"minimum":6138.4,"maximum":15565.5,"setting":"outpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":15565.5,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6662.57,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":6138.4,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Endovascular Procedures","code_information":[{"code":"5193","type":"APC"}],"standard_charges":[{"minimum":2931.66,"maximum":14108.86,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":14108.86,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2931.66,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13231.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11504.66,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13199.76,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Endovascular Procedures","code_information":[{"code":"5194","type":"APC"}],"standard_charges":[{"minimum":29855.6,"maximum":29855.6,"setting":"outpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29855.6,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Pacemaker and Similar Procedures","code_information":[{"code":"5222","type":"APC"}],"standard_charges":[{"minimum":9088.93,"maximum":9119.57,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9119.57,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9088.93,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Pacemaker and Similar Procedures","code_information":[{"code":"5223","type":"APC"}],"standard_charges":[{"minimum":12213.17,"maximum":12213.17,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12213.17,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Pacemaker and Similar Procedures","code_information":[{"code":"5224","type":"APC"}],"standard_charges":[{"minimum":20873.92,"maximum":20873.92,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":20873.92,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"minimum":559.85,"maximum":1434.09,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1434.09,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":630.09,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1340.76,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":714.65,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":559.85,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":711.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"minimum":195.82,"maximum":3992.34,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":977.48,"methodology":"other"},{"payer_name":"Aetna","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":1373.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1098.14,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1373.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":3175.52,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1264.57,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1227.84,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1406.53,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1676.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1602.35,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":973.53,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1484.46,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1893.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1728.72,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2033.08,"methodology":"other"},{"payer_name":"Healthscope Benefits","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1579.6,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1483.96,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":973.53,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1095.6,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1095.6,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":195.82,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":976.97,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1095.6,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":3320.84,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3992.34,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1728.72,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":3603.43,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1789.5,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":3541.82,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":994.13,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1206.76,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1603.55,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":11830.5,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2042.65,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2215.93,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":11830.5,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3044.22,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2802.97,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":2807.06,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4063.77,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3030.5,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2043.55,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":2043.55,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4053.54,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2042.64,"methodology":"other"},{"payer_name":"Tufts 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":1602.35,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2214.21,"methodology":"other"},{"payer_name":"United Healthcare","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":5165.01,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1206.76,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2488.8,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Upper GI Procedures","code_information":[{"code":"5303","type":"APC"}],"standard_charges":[{"minimum":4445.82,"maximum":4445.82,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4445.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":3632.18,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1061.06,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":977.56,"methodology":"other"},{"payer_name":"Aetna","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":2682.26,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1373.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1086.92,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1086.92,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1225.77,"methodology":"other"},{"payer_name":"Cdphp","plan_name":"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":3632.18,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1676.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1602.35,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1676.54,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1701.29,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1541.92,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1690.9,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1690.9,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1700.79,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":977.56,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1065.39,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":981.55,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1373.0,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2715.49,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":1690.9,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1700.79,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":977.56,"methodology":"other"},{"payer_name":"Tufts 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":1602.35,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":3285.05,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3353.27,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1690.9,"methodology":"other"},{"payer_name":"United Healthcare","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":3231.75,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":3265.67,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":3341.2,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1497.35,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1218.63,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1700.79,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1955.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"minimum":55.58,"maximum":5486.6,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1372.23,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1372.23,"methodology":"other"},{"payer_name":"Aetna","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":2340.43,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1373.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":2899.61,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1487.99,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1487.99,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1670.63,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1676.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1602.35,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1676.54,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1372.23,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1701.29,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":2450.28,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2239.23,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2339.84,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1700.79,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1376.43,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1377.83,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1267.34,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":1602.35,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":55.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1602.35,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1262.19,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1754.11,"methodology":"other"},{"payer_name":"Tufts 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":1602.35,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":5062.44,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4183.09,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2339.84,"methodology":"other"},{"payer_name":"United Healthcare","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":3445.26,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":3920.36,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":5486.6,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1287.95,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1218.63,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1755.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"minimum":118.99,"maximum":11830.5,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","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":2413.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2581.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3423.66,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3900.04,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1968.79,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":118.99,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4885.26,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3015.46,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":3015.46,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3004.7,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":11830.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8441.31,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":8725.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":3690.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Complex GI Procedures","code_information":[{"code":"5331","type":"APC"}],"standard_charges":[{"minimum":87.18,"maximum":6935.73,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6120.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6935.73,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":87.18,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5341","type":"APC"}],"standard_charges":[{"minimum":2620.14,"maximum":6021.38,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"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":3927.53,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":5662.28,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5557.35,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6021.38,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5152.4,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3715.54,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2620.14,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3700.44,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6021.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"minimum":25.11,"maximum":12904.48,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6179.45,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6798.55,"methodology":"other"},{"payer_name":"Aetna","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":2671.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2664.81,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":5032.83,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12720.28,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":7621.14,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":6765.24,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":4128.66,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10551.56,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5985.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":8562.08,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10519.85,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11099.53,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4103.13,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6196.73,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":6196.73,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":5977.46,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":554.83,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25.11,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6178.94,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6196.73,"methodology":"other"},{"payer_name":"Tufts 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":5977.46,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":11160.63,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12081.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6171.55,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":2904.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12904.48,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":9141.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":3835.96,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8085.89,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Laparoscopy and Related Services","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":18532.25,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2134.81,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18532.25,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":13054.2,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":650.0,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11457.9,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8094.06,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":15155.37,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16476.74,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":16458.18,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11042.73,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7912.5,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11012.09,"methodology":"other"},{"payer_name":"Tufts 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":7912.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18520.72,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11011.97,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":12081.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":3835.96,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5377.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"minimum":265.42,"maximum":265.42,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":265.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Urology and Related Services","code_information":[{"code":"5372","type":"APC"}],"standard_charges":[{"minimum":779.98,"maximum":925.22,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":925.22,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":779.98,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Urology and Related Services","code_information":[{"code":"5373","type":"APC"}],"standard_charges":[{"minimum":2181.57,"maximum":7352.11,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2862.89,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2538.6,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3554.32,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2393.81,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2181.57,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":5422.55,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6301.6,"methodology":"other"},{"payer_name":"United Healthcare","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":7352.11,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2278.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Urology and Related Services","code_information":[{"code":"5374","type":"APC"}],"standard_charges":[{"minimum":251.64,"maximum":8011.7,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3736.68,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3735.77,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2413.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":5886.15,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":251.64,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3215.74,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5977.46,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7459.49,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":5979.57,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3743.99,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":3743.99,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4021.34,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8011.7,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4023.48,"methodology":"other"},{"payer_name":"United Healthcare","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":6202.81,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3016.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Urology and Related Services","code_information":[{"code":"5375","type":"APC"}],"standard_charges":[{"minimum":467.33,"maximum":12806.34,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5541.87,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5541.46,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2748.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":6616.92,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":5924.99,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":5004.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12806.34,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5549.11,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":8246.5,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7490.27,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8456.85,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5557.05,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":5557.05,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":467.33,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5539.86,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":8742.03,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8781.31,"methodology":"other"},{"payer_name":"United Healthcare","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":9141.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":11744.5,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4541.73,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 6 Urology and Related Services","code_information":[{"code":"5376","type":"APC"}],"standard_charges":[{"minimum":10768.92,"maximum":10768.92,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10768.92,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Dialysis","code_information":[{"code":"5401","type":"APC"}],"standard_charges":[{"minimum":1013.65,"maximum":1013.65,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1013.65,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"minimum":200.25,"maximum":1227.2,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":408.79,"methodology":"other"},{"payer_name":"Aetna","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":855.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":240.79,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":299.25,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":286.08,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":281.26,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":267.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1079.89,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":364.76,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":255.4,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":632.06,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":374.14,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":270.79,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":448.77,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1227.2,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":776.66,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":376.66,"methodology":"other"},{"payer_name":"United Healthcare","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":915.07,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":820.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":200.25,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":341.71,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Gynecologic Procedures","code_information":[{"code":"5412","type":"APC"}],"standard_charges":[{"minimum":344.53,"maximum":344.53,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":344.53,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":344.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Gynecologic Procedures","code_information":[{"code":"5413","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":1018.0,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1018.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1013.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Gynecologic Procedures","code_information":[{"code":"5414","type":"APC"}],"standard_charges":[{"minimum":27.79,"maximum":8389.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3351.34,"methodology":"other"},{"payer_name":"Aetna","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":2497.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3707.36,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2579.35,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":3631.9,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3504.59,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4593.17,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3943.96,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1968.79,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":657.61,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1968.79,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3485.1,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2365.74,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":4939.79,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4939.79,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5055.52,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3715.47,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":3716.81,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4267.7,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":5977.46,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1675.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":27.79,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3345.94,"methodology":"other"},{"payer_name":"Tufts 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":1924.12,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":4961.42,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5938.17,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5055.51,"methodology":"other"},{"payer_name":"United Healthcare","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":8389.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":6978.28,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2530.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Gynecologic Procedures","code_information":[{"code":"5415","type":"APC"}],"standard_charges":[{"minimum":395.0,"maximum":8489.72,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":395.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5325.97,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":6848.08,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":6079.39,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":5004.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2641.49,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2600.37,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":7529.36,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8429.08,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8449.03,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5341.78,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":5341.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5325.47,"methodology":"other"},{"payer_name":"Tufts 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":4227.66,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":8489.72,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":8389.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2273.55,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3765.34,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":4128.66,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":500.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4559.16,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3333.11,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2073.58,"methodology":"other"},{"payer_name":"Medicare Advantage","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":2281.93,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":2073.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2067.15,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2319.03,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":5798.85,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":8389.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":8314.21,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1922.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Nerve Procedures","code_information":[{"code":"5432","type":"APC"}],"standard_charges":[{"minimum":816.8,"maximum":18777.33,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":816.8,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":18777.33,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":9328.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"minimum":267.96,"maximum":5849.24,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":353.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":344.45,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":407.25,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":361.12,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":419.32,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":561.78,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":561.78,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":344.95,"methodology":"other"},{"payer_name":"Medicare Advantage","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":526.63,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":318.09,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":316.79,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":316.8,"methodology":"other"},{"payer_name":"United Healthcare","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":1053.79,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":5849.24,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1183.27,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":267.96,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":2161.78,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":814.63,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":740.57,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2161.78,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":985.38,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":873.77,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1260.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1209.73,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1114.04,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1359.3,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1359.3,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1359.3,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":680.55,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":742.69,"methodology":"other"},{"payer_name":"Medicare Advantage","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":818.7,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":809.25,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":1835.46,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":680.55,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":807.96,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2002.06,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":805.97,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1613.04,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":680.55,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"minimum":500.0,"maximum":6113.34,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1462.38,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":975.71,"methodology":"other"},{"payer_name":"Aetna","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":1104.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1104.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1674.06,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1258.61,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1861.67,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1890.81,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1520.87,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":500.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1820.32,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1040.35,"methodology":"other"},{"payer_name":"Medicare Advantage","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":978.89,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1040.35,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1700.85,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1480.18,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1020.83,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":982.31,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"United Healthcare","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":6113.34,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":2762.08,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1020.83,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Neurostimulator and Related Procedures","code_information":[{"code":"5461","type":"APC"}],"standard_charges":[{"minimum":4018.69,"maximum":4018.69,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4018.69,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Neurostimulator and Related Procedures","code_information":[{"code":"5464","type":"APC"}],"standard_charges":[{"minimum":27297.1,"maximum":27297.1,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":27297.1,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 5 Neurostimulator and Related Procedures","code_information":[{"code":"5465","type":"APC"}],"standard_charges":[{"minimum":1958.05,"maximum":43169.39,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":43169.39,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1958.05,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Laser Eye Procedures","code_information":[{"code":"5481","type":"APC"}],"standard_charges":[{"minimum":624.26,"maximum":816.5,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":816.5,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":624.26,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":624.26,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","code_information":[{"code":"5503","type":"APC"}],"standard_charges":[{"minimum":2367.82,"maximum":2367.82,"setting":"outpatient","payers_information":[{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":2367.82,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"minimum":75.84,"maximum":1439.32,"setting":"outpatient","payers_information":[{"payer_name":"0","plan_name":"0","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":679.73,"methodology":"other"},{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":102.77,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":102.67,"methodology":"other"},{"payer_name":"Aetna","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":357.26,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":314.69,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":369.9,"methodology":"other"},{"payer_name":"Bind Benefits","plan_name":"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":1077.72,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":132.93,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":89.05,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":89.05,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":89.05,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":99.18,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":200.81,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":250.23,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":185.29,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":101.09,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.59,"methodology":"other"},{"payer_name":"Coresource","plan_name":"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":207.14,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":226.42,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"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":757.8,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":933.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":141.42,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":148.77,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"Healthpartners","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":177.82,"methodology":"other"},{"payer_name":"Luminare","plan_name":"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":1439.32,"methodology":"other"},{"payer_name":"Mailhandlers Benefit Plan","plan_name":"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":1212.75,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":152.66,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.59,"methodology":"other"},{"payer_name":"Medicare Advantage","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":97.59,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":102.89,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":527.09,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":252.0,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"Ppo","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":376.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":250.09,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":252.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":231.65,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.4,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":97.59,"methodology":"other"},{"payer_name":"Tufts 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":231.65,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":697.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":290.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.42,"methodology":"other"},{"payer_name":"United Healthcare","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":290.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":290.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":385.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":308.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":189.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":75.84,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":95.94,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":304.33,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"minimum":110.32,"maximum":1484.9,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":119.99,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.09,"methodology":"other"},{"payer_name":"Aetna","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":602.53,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":571.3,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":500.39,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":535.54,"methodology":"other"},{"payer_name":"Bind Benefits","plan_name":"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":441.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":252.43,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":160.83,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":160.83,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":160.83,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":119.99,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":341.41,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":312.11,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":341.41,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.07,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.07,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.7,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":129.35,"methodology":"other"},{"payer_name":"Geha","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":896.0,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":671.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":232.9,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":255.4,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":255.4,"methodology":"other"},{"payer_name":"Healthpartners","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":341.41,"methodology":"other"},{"payer_name":"Healthscope Benefits","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":329.84,"methodology":"other"},{"payer_name":"Luminare","plan_name":"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":1385.07,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.7,"methodology":"other"},{"payer_name":"Medex","plan_name":"Medicare Supplement","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1484.9,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.07,"methodology":"other"},{"payer_name":"Medicare Advantage","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":118.07,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":118.07,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":609.71,"methodology":"other"},{"payer_name":"Nalc","plan_name":"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":312.11,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1481.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":312.11,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.7,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":352.71,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.55,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.07,"methodology":"other"},{"payer_name":"Tufts 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":257.88,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":963.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":733.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":255.4,"methodology":"other"},{"payer_name":"United Healthcare","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":733.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":733.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":232.9,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":954.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":217.87,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.7,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":153.51,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":110.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"minimum":156.7,"maximum":2239.5,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":266.4,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":282.22,"methodology":"other"},{"payer_name":"Aetna","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":1269.58,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":689.04,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":715.14,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":523.37,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":329.58,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":517.3,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Indemnity","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1035.22,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":379.41,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":267.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":341.41,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":681.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":327.65,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":263.16,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":237.24,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":2239.5,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":477.26,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":523.37,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":523.37,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":235.05,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":263.16,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":263.16,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":689.04,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":726.34,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.7,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":281.32,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":282.47,"methodology":"other"},{"payer_name":"Tufts 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":550.32,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":2011.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":870.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":523.37,"methodology":"other"},{"payer_name":"United Healthcare","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":2125.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":870.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":870.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":267.44,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":542.5,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":204.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"minimum":224.0,"maximum":2230.98,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":594.37,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":592.61,"methodology":"other"},{"payer_name":"Aetna","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":2025.43,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1413.72,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":725.93,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1036.69,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":818.66,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":983.81,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2230.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":944.14,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":614.27,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":224.0,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":1436.93,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1029.8,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1129.3,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1129.3,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":592.48,"methodology":"other"},{"payer_name":"Medicare Advantage","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":640.72,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":640.72,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":224.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":590.47,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":592.48,"methodology":"other"},{"payer_name":"Tufts 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":1184.39,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1436.93,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1436.93,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1129.3,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":1436.93,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":575.42,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":344.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"minimum":169.85,"maximum":3004.37,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":297.53,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":210.98,"methodology":"other"},{"payer_name":"Aetna","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":1473.73,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1897.93,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":1446.8,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":452.63,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3004.37,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":452.63,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":169.85,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":189.2,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":206.98,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":417.6,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":457.95,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":457.95,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":208.03,"methodology":"other"},{"payer_name":"Medicare Advantage","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":298.03,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":298.03,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":204.11,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.53,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1446.8,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":457.95,"methodology":"other"},{"payer_name":"United Healthcare","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":1760.1,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":1760.1,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":1840.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"Ppo","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":768.03,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":204.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"minimum":204.11,"maximum":2742.5,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":415.14,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":413.34,"methodology":"other"},{"payer_name":"Aetna","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":1988.59,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2212.7,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":1985.42,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":865.79,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":865.79,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":419.73,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":257.18,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1073.8,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1387.24,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":204.11,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":875.95,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":875.95,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":918.39,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":204.11,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":413.01,"methodology":"other"},{"payer_name":"Medicare Advantage","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":417.32,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":413.01,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":471.74,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":415.63,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":419.73,"methodology":"other"},{"payer_name":"Tufts 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":887.22,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":2742.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1456.51,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":875.95,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":1840.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":2239.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1079.13,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":279.95,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":3145.06,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":856.4,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2333.55,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1337.16,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":2338.46,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":859.9,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":873.08,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":919.88,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":3145.06,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1899.75,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Nuclear Medicine and Related Services","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"minimum":143.0,"maximum":2544.38,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":467.66,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":444.15,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":992.9,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":505.3,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":505.3,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":428.54,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1907.34,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1907.34,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":924.93,"methodology":"other"},{"payer_name":"Medicare Advantage","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":442.95,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":928.17,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":143.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2544.38,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":767.07,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Nuclear Medicine and Related Services","code_information":[{"code":"5592","type":"APC"}],"standard_charges":[{"minimum":442.01,"maximum":1572.15,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":583.13,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1341.65,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":651.14,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":651.14,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":651.14,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1214.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":664.26,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":942.93,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1034.03,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1034.03,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":580.48,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":580.48,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts 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":1471.56,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1367.34,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1572.15,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":442.01,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Nuclear Medicine and Related Services","code_information":[{"code":"5593","type":"APC"}],"standard_charges":[{"minimum":200.0,"maximum":5295.98,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1522.59,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1521.58,"methodology":"other"},{"payer_name":"Aetna","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":368.55,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1597.2,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3126.48,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3173.51,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":931.53,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5295.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":955.27,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":310.07,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3363.43,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3363.43,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1065.44,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1524.98,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1524.98,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1523.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1524.98,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2904.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1519.19,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":4500.39,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1065.44,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Nuclear Medicine and Related Services","code_information":[{"code":"5594","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":6817.79,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1700.52,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1676.13,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":3086.25,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3086.25,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":3261.9,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4325.34,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":2847.37,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3122.48,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3273.79,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1497.74,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1680.16,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1704.45,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1680.16,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1471.64,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1678.33,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":6817.79,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1697.52,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":6813.36,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":3016.61,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1471.64,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5611","type":"APC"}],"standard_charges":[{"minimum":58.28,"maximum":3649.07,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":305.13,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":566.16,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":280.96,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":58.28,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":505.67,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3649.07,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":154.52,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":114.42,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5612","type":"APC"}],"standard_charges":[{"minimum":233.78,"maximum":2584.86,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":855.56,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":685.46,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2543.11,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":736.04,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":509.56,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":618.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1433.3,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1233.03,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":922.37,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1011.49,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":233.78,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":688.26,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2584.86,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":790.4,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2052.75,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":984.38,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":419.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5613","type":"APC"}],"standard_charges":[{"minimum":677.57,"maximum":8970.92,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2336.98,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2167.51,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2382.15,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":2014.13,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":6110.26,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":4312.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":4312.01,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3998.11,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":870.54,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":2322.08,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7513.84,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":8970.92,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1503.9,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2327.46,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":3124.61,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":677.57,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Radiation Therapy","code_information":[{"code":"5621","type":"APC"}],"standard_charges":[{"minimum":51.51,"maximum":51.51,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":51.51,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Radiation Therapy","code_information":[{"code":"5622","type":"APC"}],"standard_charges":[{"minimum":122.92,"maximum":984.52,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":307.31,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":719.14,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":256.68,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":256.68,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":541.91,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":750.68,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":298.95,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":370.21,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":464.63,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":509.52,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":509.52,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":370.21,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":122.92,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":307.3,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":288.65,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":730.94,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":306.06,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":984.52,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":370.21,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Radiation Therapy","code_information":[{"code":"5623","type":"APC"}],"standard_charges":[{"minimum":137.39,"maximum":2672.92,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":675.98,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":629.63,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2243.74,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":594.48,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":594.48,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1596.56,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1669.59,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":137.39,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1237.24,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1180.06,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":252.88,"methodology":"other"},{"payer_name":"Medicare Advantage","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":675.98,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":632.2,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2672.92,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2280.57,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":673.23,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":827.76,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":746.73,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 6 Radiation Therapy","code_information":[{"code":"5626","type":"APC"}],"standard_charges":[{"minimum":820.74,"maximum":820.74,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":820.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Therapeutic Nuclear Medicine","code_information":[{"code":"5661","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":794.74,"setting":"outpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":794.74,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Pathology","code_information":[{"code":"5671","type":"APC"}],"standard_charges":[{"minimum":38.38,"maximum":677.4,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":57.96,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":57.96,"methodology":"other"},{"payer_name":"Aetna","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":166.62,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":155.1,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":592.3,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":100.0,"methodology":"other"},{"payer_name":"Bind Benefits","plan_name":"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":100.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":58.3,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":116.6,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":58.3,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":57.36,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":439.81,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":57.36,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":57.96,"methodology":"other"},{"payer_name":"Geha","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.0,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":100.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":211.06,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":115.72,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":115.72,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":54.93,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":58.19,"methodology":"other"},{"payer_name":"Medicare Advantage","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":58.19,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":62.43,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":465.3,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.0,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":677.4,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":146.6,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":48.02,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":121.13,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":57.96,"methodology":"other"},{"payer_name":"Tufts 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":199.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":100.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":115.72,"methodology":"other"},{"payer_name":"United Healthcare","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":200.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":157.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":200.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":59.14,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":149.25,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":51.88,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":38.38,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Pathology","code_information":[{"code":"5672","type":"APC"}],"standard_charges":[{"minimum":85.0,"maximum":2274.75,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":199.43,"methodology":"other"},{"payer_name":"Aetna","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":773.42,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":827.72,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":1321.78,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":402.98,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":435.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":699.12,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1043.25,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":199.43,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":466.06,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":810.24,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":274.28,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":183.44,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":200.24,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":182.69,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":85.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":700.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":559.98,"methodology":"other"},{"payer_name":"United Healthcare","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":405.12,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":600.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":2274.75,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":270.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Pathology","code_information":[{"code":"5673","type":"APC"}],"standard_charges":[{"minimum":280.03,"maximum":2221.56,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":418.65,"methodology":"other"},{"payer_name":"Aetna","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":280.03,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2221.56,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":581.27,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1881.54,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":833.74,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1398.63,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1347.85,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":305.55,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":411.93,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":567.64,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1094.21,"methodology":"other"},{"payer_name":"Health Scope Benefits","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1067.98,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":420.36,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":386.03,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":822.89,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":539.71,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":288.43,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":390.81,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":418.65,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":300.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":400.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1107.84,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":399.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":669.67,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":854.3,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"minimum":820.0,"maximum":3044.21,"setting":"outpatient","payers_information":[{"payer_name":"Cigna","plan_name":"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":3044.21,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1980.21,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2904.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":820.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"minimum":135.63,"maximum":10203.84,"setting":"outpatient","payers_information":[{"payer_name":"0","plan_name":"0","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":135.63,"methodology":"other"},{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":596.72,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":182.52,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":373.67,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":3677.58,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1981.84,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":464.12,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":496.37,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":473.91,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":327.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10203.84,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1831.92,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1733.94,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2578.71,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1750.04,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":312.14,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2412.12,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1666.94,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1667.38,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1667.38,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":10089.13,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1660.6,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1835.17,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1656.17,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"United Healthcare","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":3546.05,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":541.14,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":538.59,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":259.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"minimum":186.65,"maximum":622.67,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":233.93,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":398.18,"methodology":"other"},{"payer_name":"Aetna","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":401.52,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":409.08,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":463.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":335.09,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":273.13,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":461.78,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":576.96,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":238.42,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":219.37,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":387.46,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":424.9,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":424.9,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":219.37,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":230.19,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":377.91,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":622.67,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":229.25,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":423.18,"methodology":"other"},{"payer_name":"Tufts 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":600.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":437.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":424.9,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":290.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":186.65,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":306.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"minimum":429.57,"maximum":24779.86,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":11772.58,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":488.4,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":7440.74,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":13170.98,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3848.59,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3456.05,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":429.57,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12723.55,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1100.54,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3792.49,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":12927.62,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1139.78,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":5971.77,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":11962.6,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":3855.46,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":24779.86,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":7971.24,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":1282.22,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":608.53,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"minimum":167.47,"maximum":1095.61,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":182.6,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":182.99,"methodology":"other"},{"payer_name":"Aetna","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":936.1,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":871.37,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":936.1,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":335.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":335.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":671.58,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":395.27,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":281.42,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":308.61,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":308.61,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":167.75,"methodology":"other"},{"payer_name":"Medicare Advantage","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":167.75,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":182.84,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":469.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":375.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":167.47,"methodology":"other"},{"payer_name":"Tufts 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":375.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1095.61,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":899.99,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":308.61,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":899.99,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":899.99,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":485.4,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":213.24,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"minimum":73.96,"maximum":1454.36,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":336.72,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":335.72,"methodology":"other"},{"payer_name":"Aetna","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":1454.36,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1294.58,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":736.32,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":415.19,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":398.23,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1188.59,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":685.6,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":73.96,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":572.74,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":572.74,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":814.45,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":337.09,"methodology":"other"},{"payer_name":"Medicare Advantage","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":337.09,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":337.09,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1307.39,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":1399.5,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":341.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":336.12,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":938.63,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1375.75,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":572.74,"methodology":"other"},{"payer_name":"United Healthcare","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":891.14,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":938.63,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":501.87,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":341.78,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Diagnostic Tests and Related Services","code_information":[{"code":"5723","type":"APC"}],"standard_charges":[{"minimum":664.32,"maximum":664.32,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","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":664.32,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Diagnostic Tests and Related Services","code_information":[{"code":"5724","type":"APC"}],"standard_charges":[{"minimum":1118.5,"maximum":2197.91,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1184.55,"methodology":"other"},{"payer_name":"Aetna","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":2157.3,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2197.91,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":1502.07,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1331.93,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1825.31,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1825.31,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1122.86,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1980.75,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2072.03,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2072.03,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1122.86,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1122.86,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1359.12,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1181.84,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1118.5,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2072.03,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1181.84,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"minimum":43.77,"maximum":458.69,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":185.9,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":91.05,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":80.73,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":145.97,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":93.2,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":231.06,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":241.71,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":45.86,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":229.3,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":191.27,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":128.67,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":458.69,"methodology":"other"},{"payer_name":"United Healthcare","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":195.62,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":262.62,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":182.25,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"minimum":25.43,"maximum":770.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":70.13,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":66.22,"methodology":"other"},{"payer_name":"Aetna","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":741.29,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":155.23,"methodology":"other"},{"payer_name":"Anthem","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":770.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":102.9,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":224.19,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":221.06,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":184.03,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":108.56,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":65.69,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":317.46,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":500.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":121.3,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":188.63,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":128.7,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":65.69,"methodology":"other"},{"payer_name":"Medicare Advantage","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":277.64,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":65.69,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":320.33,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":279.78,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":337.36,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25.43,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":65.82,"methodology":"other"},{"payer_name":"Tufts 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":546.65,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":290.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":329.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":196.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":66.76,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":577.5,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":36.11,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"minimum":13.9,"maximum":1733.0,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.64,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":150.02,"methodology":"other"},{"payer_name":"Aetna","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":1038.94,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":614.6,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":1342.88,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":380.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":287.83,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":259.19,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":265.77,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":209.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":581.21,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":362.54,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":142.1,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":13.9,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":407.51,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":440.82,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":436.81,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":123.12,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":137.19,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":137.19,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":593.67,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":342.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":437.2,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":192.01,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":110.2,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1733.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.63,"methodology":"other"},{"payer_name":"Tufts 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":324.12,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":285.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":488.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":494.74,"methodology":"other"},{"payer_name":"United Healthcare","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":399.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":342.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":285.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":166.32,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":275.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":80.97,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":116.61,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Level 1 Electronic Analysis of Devices","code_information":[{"code":"5741","type":"APC"}],"standard_charges":[{"minimum":40.34,"maximum":40.34,"setting":"outpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":40.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"minimum":117.19,"maximum":2916.92,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":848.04,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":735.7,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2916.92,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":500.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":972.1,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":1179.1,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2390.15,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":1467.42,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1711.99,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1968.4,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":882.84,"methodology":"other"},{"payer_name":"Medicare Advantage","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":1324.26,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":1277.19,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":820.33,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":848.03,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":562.4,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":2836.82,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1153.76,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":747.74,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":117.19,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Resuscitation and Cardioversion","code_information":[{"code":"5781","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":2337.6,"setting":"outpatient","payers_information":[{"payer_name":"Blue Cross Blue Shield","plan_name":"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":2337.6,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":1777.62,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1089.83,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":698.95,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":764.69,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1948.53,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":761.58,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"minimum":206.71,"maximum":1135.45,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"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":270.15,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":316.53,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":280.71,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":206.71,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":368.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":914.93,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1126.27,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":1135.45,"methodology":"other"}],"billing_class":"facility"}]},{"description":"RBC leukoreduced irradiated","code_information":[{"code":"9522","type":"APC"}],"standard_charges":[{"minimum":300.0,"maximum":963.09,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":963.09,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":300.0,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Plate pheres leukoredu irrad","code_information":[{"code":"9530","type":"APC"}],"standard_charges":[{"minimum":1491.34,"maximum":1491.34,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1491.34,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Platelets pheresis path redu","code_information":[{"code":"9536","type":"APC"}],"standard_charges":[{"minimum":1021.79,"maximum":1021.79,"setting":"outpatient","payers_information":[{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1021.79,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Non-OPPS Clinic Services","code_information":[{"code":"N700","type":"APC"}],"standard_charges":[{"minimum":30.09,"maximum":446.58,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","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":168.5,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":156.82,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":197.21,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":198.0,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30.09,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":249.0,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":195.9,"methodology":"other"},{"payer_name":"Geha","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.45,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":289.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"Luminare","plan_name":"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":162.76,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":181.22,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":190.49,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":287.39,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":162.76,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":30.09,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":160.42,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":30.09,"methodology":"other"},{"payer_name":"Tufts 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":30.09,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":200.45,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":198.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.0,"methodology":"other"},{"payer_name":"United Healthcare","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":198.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":200.45,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":200.45,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":159.39,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":195.9,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":152.66,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":263.31,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"minimum":14.38,"maximum":1101.0,"setting":"outpatient","payers_information":[{"payer_name":"#N/A","plan_name":"#N/A","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":399.0,"methodology":"other"},{"payer_name":"0","plan_name":"0","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":399.0,"methodology":"other"},{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":49.95,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":47.07,"methodology":"other"},{"payer_name":"Aetna","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":337.0,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":323.93,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":394.37,"methodology":"other"},{"payer_name":"All Savers","plan_name":"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":114.22,"methodology":"other"},{"payer_name":"Anthem","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":495.0,"methodology":"other"},{"payer_name":"Bind Benefits","plan_name":"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":684.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":114.85,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":29.63,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":72.18,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":70.63,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":79.62,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Indemnity","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":118.74,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":60.78,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":114.54,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":98.52,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":114.71,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25.54,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":37.43,"methodology":"other"},{"payer_name":"Coresource","plan_name":"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":339.49,"methodology":"other"},{"payer_name":"Empire Nyship","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1101.0,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":194.33,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"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":437.4,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":83.64,"methodology":"other"},{"payer_name":"Geha","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":157.0,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":171.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Ppo","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":104.23,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":107.53,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","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":37.98,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":105.22,"methodology":"other"},{"payer_name":"Healthscope Benefits","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":180.01,"methodology":"other"},{"payer_name":"Luminare","plan_name":"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":339.49,"methodology":"other"},{"payer_name":"Mailhandlers Benefit Plan","plan_name":"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":378.69,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":18.23,"methodology":"other"},{"payer_name":"Medica","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":277.0,"methodology":"other"},{"payer_name":"Medical Mutual","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":122.02,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":47.44,"methodology":"other"},{"payer_name":"Medicare Advantage","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":42.25,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":49.71,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.97,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":183.0,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":345.8,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":144.19,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":76.02,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":54.66,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":117.93,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":25.98,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":19.87,"methodology":"other"},{"payer_name":"Tufts 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":123.78,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":157.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":228.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":87.69,"methodology":"other"},{"payer_name":"United Healthcare","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":228.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":228.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"United Healthcare Surest Plan","plan_name":"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":280.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":14.38,"methodology":"other"},{"payer_name":"Web Tpa","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":84.25,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":143.41,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":36.79,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":44.85,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":48.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"minimum":2.39,"maximum":1692.64,"setting":"outpatient","payers_information":[{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":137.28,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’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":"Aetna","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":322.22,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":310.46,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":185.88,"methodology":"other"},{"payer_name":"Anthem","plan_name":"Medicare Supplement","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":164.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":292.41,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":124.89,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":207.53,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":240.69,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":613.47,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":363.14,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":82.84,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":211.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":313.32,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":343.59,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":343.59,"methodology":"other"},{"payer_name":"Mailhandlers Benefit Plan","plan_name":"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":296.06,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":116.99,"methodology":"other"},{"payer_name":"Medex","plan_name":"Medicare Supplement","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":2.39,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":206.79,"methodology":"other"},{"payer_name":"Medicare Advantage","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":84.72,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":211.89,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":173.03,"methodology":"other"},{"payer_name":"Nippon Life Ins","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":409.44,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":178.71,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":146.86,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":155.99,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":324.87,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.42,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":143.94,"methodology":"other"},{"payer_name":"Tufts 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":140.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":222.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":315.56,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":261.77,"methodology":"other"},{"payer_name":"United Healthcare","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":315.56,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":489.0,"methodology":"other"},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":592.8,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":315.56,"methodology":"other"},{"payer_name":"Web Tpa","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":1692.64,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":294.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":105.19,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":116.09,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"minimum":135.87,"maximum":813.02,"setting":"outpatient","payers_information":[{"payer_name":"0","plan_name":"0","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":773.0,"methodology":"other"},{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.19,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.18,"methodology":"other"},{"payer_name":"Aetna","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":647.23,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":322.76,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":647.23,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":249.5,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":249.5,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":249.5,"methodology":"other"},{"payer_name":"Champva","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":138.96,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":377.7,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":319.44,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":362.48,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.63,"methodology":"other"},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":141.63,"methodology":"other"},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":288.53,"methodology":"other"},{"payer_name":"Geha","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":773.0,"methodology":"other"},{"payer_name":"Geha","plan_name":"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":773.0,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":232.02,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":243.24,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":254.45,"methodology":"other"},{"payer_name":"Luminare","plan_name":"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":813.02,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":135.87,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.18,"methodology":"other"},{"payer_name":"Medicare Advantage","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":136.74,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":136.74,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":331.2,"methodology":"other"},{"payer_name":"Optum","plan_name":"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":136.19,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":773.0,"methodology":"other"},{"payer_name":"Trustmark","plan_name":"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":635.41,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":319.44,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":135.87,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":277.61,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.18,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":136.18,"methodology":"other"},{"payer_name":"Tufts 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":277.61,"methodology":"other"},{"payer_name":"Ultra Benefits","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":362.48,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":773.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":773.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":254.45,"methodology":"other"},{"payer_name":"United Healthcare","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":773.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":773.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":773.0,"methodology":"other"},{"payer_name":"Va Optum","plan_name":"Veterans Plan","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":138.96,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":233.74,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":135.87,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Durable Medical Equipment","code_information":[{"code":"N805","type":"APC"}],"standard_charges":[{"minimum":327.85,"maximum":327.85,"setting":"outpatient","payers_information":[{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":327.85,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Other Medicine","code_information":[{"code":"N809","type":"APC"}],"standard_charges":[{"minimum":155.65,"maximum":993.6,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","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":321.52,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":218.8,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":993.6,"methodology":"other"},{"payer_name":"Medicare","plan_name":"Medicare","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":237.21,"methodology":"other"},{"payer_name":"Medicare Advantage","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":411.37,"methodology":"other"},{"payer_name":"Medicare Advantage","plan_name":"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":411.28,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":155.65,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"minimum":16.0,"maximum":791.0,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","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":599.1,"methodology":"other"},{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":537.88,"methodology":"other"},{"payer_name":"Aetna","plan_name":"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":669.0,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":190.71,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":143.73,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":253.64,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":144.23,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":203.09,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":275.48,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":203.09,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":220.83,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":237.27,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":242.16,"methodology":"other"},{"payer_name":"Masshealth","plan_name":"Medicaid","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":84.41,"methodology":"other"},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":791.0,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":128.8,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":86.68,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":267.16,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":22.64,"methodology":"other"},{"payer_name":"Tufts 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":299.0,"methodology":"other"},{"payer_name":"Umr","plan_name":"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":16.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":442.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":258.28,"methodology":"other"},{"payer_name":"United Healthcare","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":791.0,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":399.0,"methodology":"other"},{"payer_name":"United Healthcare Surest Plan","plan_name":"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":228.0,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":403.0,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":80.24,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":193.74,"methodology":"other"},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":47.91,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"minimum":446.58,"maximum":446.58,"setting":"outpatient","payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"}],"billing_class":"facility"}]},{"description":"Not Recognized by OPPS","code_information":[{"code":"N905","type":"APC"}],"standard_charges":[{"minimum":30.09,"maximum":446.58,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":217.26,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","plan_name":"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":224.16,"methodology":"other"},{"payer_name":"Blue Cross Blue Shield","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":212.51,"methodology":"other"},{"payer_name":"Cigna","plan_name":"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":170.6,"methodology":"other"},{"payer_name":"Cigna","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":60.19,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"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":193.96,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":106.35,"methodology":"other"},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":212.7,"methodology":"other"},{"payer_name":"Meritain","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":217.26,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"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":30.09,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":446.58,"methodology":"other"},{"payer_name":"Tufts Health Plan","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":60.19,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Pos","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":228.62,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm.","standard_charge_algorithm":"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.","estimated_amount":106.35,"methodology":"other"},{"payer_name":"United Healthcare","plan_name":"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":228.62,"methodology":"other"},{"payer_name":"Wellpoint Gic","plan_name":"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":106.5,"methodology":"other"}],"billing_class":"facility"}]}],"modifier_information":[{"description":"Modifier description not available","code":"SPE","modifier_payer_information":[{"payer_name":"#N/A","plan_name":"#N/A","description":"The modified price is presented in the standard charge value."},{"payer_name":"0","plan_name":"0","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aarp Medicare Complete","plan_name":"Medicare Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Hmo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"All Savers","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Anthem","plan_name":"Medicare Supplement","description":"The modified price is presented in the standard charge value."},{"payer_name":"Anthem","plan_name":"Qhp","description":"The modified price is presented in the standard charge value."},{"payer_name":"Bind Benefits","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Blue Cross Blue Shield","plan_name":"Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"Blue Cross Blue Shield","plan_name":"Hmo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Blue Cross Blue Shield","plan_name":"Indemnity","description":"The modified price is presented in the standard charge value."},{"payer_name":"Blue Cross Blue Shield","plan_name":"Medicare Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Blue Cross Blue Shield","plan_name":"Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"Blue Cross Blue Shield","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cdphp","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Champva","plan_name":"Veterans Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"Hmo/Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Commonwealth Care Alliance","plan_name":"Medicare Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Commonwealth Care Alliance","plan_name":"Senior Care Options","description":"The modified price is presented in the standard charge value."},{"payer_name":"Coresource","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Empire Nyship","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Fallon Health Plan","plan_name":"Hmo/Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Fallon Health Plan","plan_name":"Medicaid Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Fallon Health Plan","plan_name":"Medicare Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Geha","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Geha","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Hmo/Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Health Scope Benefits","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Healthpartners","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Healthscope Benefits","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Luminare","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mailhandlers Benefit Plan","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Masshealth","plan_name":"Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"Masshealth","plan_name":"Medicaid","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medex","plan_name":"Medicare Supplement","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medica","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medical Mutual","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medicare","plan_name":"Medicare","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medicare Advantage","plan_name":"Hmo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Medicare Advantage","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Meritain","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Nalc","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Nippon Life Ins","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Optum","plan_name":"Behavioral Health","description":"The modified price is presented in the standard charge value."},{"payer_name":"Oxford Health","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Trustmark","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Hmo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Medicaid Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Medicare Supplement","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Qhp","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tufts Health Plan","plan_name":"Senior Care Options","description":"The modified price is presented in the standard charge value."},{"payer_name":"Ultra Benefits","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Umr","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"United Healthcare","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"United Healthcare","plan_name":"Hmo","description":"The modified price is presented in the standard charge value."},{"payer_name":"United Healthcare","plan_name":"Pos","description":"The modified price is presented in the standard charge value."},{"payer_name":"United Healthcare","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"United Healthcare Student Resources","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"United Healthcare Surest Plan","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Va Optum","plan_name":"Veterans Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Web Tpa","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellpoint Gic","plan_name":"Ppo","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellsense Health Plan","plan_name":"Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Advantage","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellsense Health Plan","plan_name":"Qhp","description":"The modified price is presented in the standard charge value."}]}]}